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Canadian  Institute  for  Historical  Microreproductions  /  Institut  Canadian  de  microreproductiona  historlquea 


:\ 


Technical  and  Bibliographic  Notes/Notes  techniques  et  bibliographiques 


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D 


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n 


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D 
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D 
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et  de  haut  en  bas,  en  prenant  le  nombre 
d'images  n4cessairs.  Les  diagrammes  sulvants 
lllustrent  la  mAthode. 


1 

2 

3 

32X 


1 

2 

3 

4 

5 

6 

A    MANUAL 


OF  THE 


PRINCIPLES  OF  SURGERY, 


BASED    ON   PATHOLOGY 


FOR    STUDEJSTTS. 


By  WILLIAM  CANNIFF, 

LICKWUT.  OF  TH.  «»IOAl  BOAKB  OF  UFMR  OAITADA;  M.D.  OF  IB.  rK,V.M.IT  OF  K.W  YORK  • 

•..E.C.B.,E«OLAK»;  FORMRLT  H0U8.  8««0K0»  ,0  TB.  8»A1.«-B  B08PITAL,  ».W  TOM 

FOR  80IIE   Tin  A.  A.  8URaiON  TO  BER  BRITAKMO  MAJMTT'S  FOROM;    lATl  ' 

PR0FI880R  OF  OElflRAl  PAIBOIOOT  AWD  THE  PRI!tOIPlE8  AND  PRAC 

Tioi  OF  snROERr,  rwv.  TIOTDRIA  COLUOE,  TOROWTO,  O.W.I 

ABB  FOR  A  8H0BT  TIME  A.  A.  8CR0I0II  10 

TBI  DNITID  STATU  ARNT. 


PHILADELPHIA: 
LINDSAY    &    BLAKI8T0N. 


1 


oat! 


VS\^'^}. . 


Entered,  according  to  Act  of  Congress,  in  the  year  1866, 

Br  Lindsay   A   BiiAKisTON, 

In  the  Clerk's  OfiBoe  of  the  District  Court  of  the  United  States  for  the  Eastern 
District  of  Pennsylvania. 


SHERMAN    &    CO.,    FRIMTERB. 


FREF  AC  E. 


This  volume  was  commenced  while  the  author  was  engaged  in 
lecturing  upon  the  Principles  and  Practice  of  Surgery.  Finding 
that  a  single  session,  although  of  six  months,  was  not  suflBciently 
long  to  permit  him  to  embrace  in  his  course  both  the  principles 
and  the  practice  of  the  science,  he  proposed  to  himself  to  prepare 
a  handbook  of  the  principles  for  his  class,  that  he  might  thereby 
he  enabled  to  devote  more  time  to  the  practical  part  of  the  sub- 
ject. Circumstances  having  led  to  his  withdrawal  from  the  col- 
lege, he  has  been  induced  to  extend  the  limits  of  the  work  to  the 
present  size,  ia  the  hope  that  it  may  be  found  more  useful.  In 
doing  so  great  attention  has  been  devoted  to  surgical  pathology, 
believing  that  it  is  most  essential  to  a  knowledge  of  all  rational 
treatment.  The  groundwork  is  mainly  derived  from  the  lectures 
delivered  by  him  opon  General  Pathology  and  Surgery.  In  the 
preparation  of  those  lectures  the  following  works  were  freely  con- 
sulted :  Rokitansky's,  Jones  and  Sieveking's,  and  Gross's  Patho- 
logical Anatomy,  Simon's  General  Pathology,  Principles  and 
Practice  of  Surgery  by  Miller,  Cooper's  Surgical  Dictionary, 
Chelius's  System  of  Surgery,  and  especially  Paget's  Surgical  Pa- 
thology. Other  works  were  also  often  examined.  And  in  com- 
pleting the  work  much  assistance  has  been  obtained  from  Virchow's 
Cellular  Pathology  and  Holmes's  System  of  Surgery.  It  follows 
that  much  contained  in  these  pages  may  be  found  in  those  works, 
and  it  gives  the  author  pleasure  to  thus  make  this  distinct  acknow- 
ledgment.   But  the  author,  in  appropriating  the  labors  of  others, 


IV 


PREFACE. 


was  Steadily  careful  to  exclude  what  seemed  irrelevant  or  unne- 
cessary for  his  purpose,  ever  endeavoring  to  simplify  the  subject 
under  consideration  by  avoiding  useless  technicalities;  while  at 
the  same  time  embodying  such  appropriate  facts  as  had  come 
under  his  personal  observation,  and  advancing  such  theories  as 
thought  and  study  had  suggested  to  his  mind.  The  illustrations, 
as  will  be  seen,  are  taken  from  Paget's  Surgical  Pathology. 

The  arrangement  and  division  of  subjects  are  original,  and  the 
hope  is  entertained  that  they  will  be  found  advantageous  to  the 
student.  The  work  has  been  prepared  more  particularly  for  the 
student,  but  the  opinion  is  hazarded  that  it  will  prove  useful  to 
the  practitioner. 

That  in  these  pages  there  will  be  found  many  imperfections  is 
very  well  known;  but  the  profession  is  requested  to  remember  that 
this  is  the  first  undertaking  of  the  kind  in  our  young  country. 
The  writer  enjoyed  not  the  advantages  of  early  literary  training. 
As  his  grandfathers  and  his  father  were  pioneers  in  the  wilderness 
of  Canada,  and  paved  the  way  for  a  more  scientific  agriculture,  so 
the  writer  hopes  this  volume  will  be  the  forerunner  of  other  and 
more  excellent  treatises,  that  will  hereafter  proceed  from  the  pro- 
fession of  our  province. 

Not  having  personally  superintended  the  work  through  the 
press,  there  may  consequently  be  found  a  few  blemishes  which 
the  printer  and  proof-reader  could  not  feel  at  liberty  to  remove. 

Bellevillb,  Canada  West,  January,  1866. 


CONTENTS. 


CHAPTER  I. 


PASS 


Nutrition— Development— Growth— Assimilation— The  "  Formative 
Process"— Ordinary  Decay— Repair— Pour  conditions  necessary 
for  Repair, j- 


X)i-viszo3sr  I. 

INFLAMMATION,   AND  DI8KA8B8  ARISING  OUT  OF  INFLAMMATION. 


CHAPTER  II. 

Inflammatory  Process— Incubation— Congestion— Inflammation  Esta- 
blished-Stagnation— Changes  in  Blood— Fibrin— Change  of  Func- 
tion,     


24 


CHAPTER  III. 

More  Extensive  View-Number  of  Products,  viz..  Serum,  Liquor  San- 
guinis, Fibrin,  or  Inflammatory  Lymph,  «&c.— Causes  of  Inflam- 
mation— Various  Divisions,       .... 


84 


CHAPTER  IV. 

Symptoms  of  Inflammation— Causes  of  each— Value  in  Diag 


nosis. 


38 


CHAPTER  V. 

Prognosis  of  Inflammation— Course  and  Termination,  viz. :  1.  Resolu- 
tion.  2.  Delitescence.  8.  Extension,  first,  by  Continuity ;  second, 
by  Contiguity ;  third,  by  the  Circulation— Each  explained-Fibrin 
in  the  System  and  out  of' it-"  Cupped  and  Bufi-ed ;"  fourth,  by  ab- 
sorption ;  fifth,  by  the  agency  of  the  nerves,     ... 


46 


VI 


CONTENTS. 


CHAPTER  VI. 


PAM 


The  Products  of  Inflammation:  1.  Serum;  2.  Liquor  Sanguinis— Fi- 
brin—Coagulation— Development— Hypertrophy,  True  and  False- 
Atrophy — Induration, g2 


CHAPTER  VII. 

Products  of  Inflammation— Degeneration  of  Lymph— Corpuscular  and 
Fibrinous  Elements— Cause  of  each— 1.  Pus :  How  formed ;  Differ- 
ent ways  found— 1.  Abscess ;  2.  Diffused ;  3.  Upon  the  Surface— 2d 
Formof  Degeneration  of  Pus— Fatty ;  3d.  Calcareous;  4th.  Pigmen- 
tal—Blood as  a  Product — Changed  Mucus, 


57 


CHAPTER  VIII. 

Treatment  of  Inflammation— In  its  First  Steps— 1.  Nature  as  a  Guide. 
2.  Prevention  of  Further  Progress.  8.  Sedatives.  4.  Cold.  5. 
Heat.    6.  Stimulants.     7.  Astringents, 


66 


CHAPTER  IX. 

Treatment  continued— Evacuants,  including  Derivatives,  Emetics,  Pur- 
gatives, Diuretics,  Diaphoretics— General  Bleeding— Direct  Evacu- 
ation of  Blood— Cupping— Leeching— Puncturing— Counter-irri- 
tants— Rubefacients — Pressure,  .        .        ,        •        . 


74 


CHAPTER  X. 

Constitutional  Treatment— Special  Medicines— Antimony*-Mercury— 
Opiates— Veratrum  Viride— Aconite—Nitrate  of  Silver— Potash,  . 


84 


CHAPTER  XI. 


Treatment  of  the  Products  of  Inflammation— Of  Serum— Liquor  San- 
guinis— False  Hypertrophy— Induration— Atrophy— Degenerated 
Lymph— Pus— Abscess— Pointing  of  Abscess— Diffused  Pus— Mu- 
cus— Blood, 


90 


CONTENTS.  Vii 

CHAPTER  XII. 

PAM 

DiseaseB  arising  out  of  Inflammation— Passive  :  1.  Congestion ;  Results 
—Treatment,  Local  and  General.  2.  Chronic  Inflammation ;  Pro- 
ducts— Treatment 101 

CHAPTER  XIII. 

Chronic  Abscess— Results— Treatment— Sinus  or  Fistula— Treatment,  .      107 

CHAPTER  XIV. 

Pyemia  —  Causes  —  Treatment  —  Softening — Ulceration— Sloughing— 

Gangrene — Treatment, 115 

CHAPTER  XV. 

Varieties  of  Inflammation— Phlegmon— Anthrax— Chilblains— Frost- 
bites— Burns 125 

CHAPTER  XVI. 

Scrofulous  Inflammation— Causes ;  Tubercle— Scrofula— Terminations 

— Treatment, 186 

CHAPTER  XVII. 
Gonorrhoeal  Inflammation, 144 

CHAPTER  XVIII. 

Syphilitic  Inflammation— Pathology— Question  of  Duality— Hard  Chan- 
cre—Its Treatment— Soft  Chancre— Its  Treatment— Buboes— Treat- 
ment of  Buboes — Constitutional  Treatment  of  Syphilis,   .        .        .149 

CHAPTER  XIX. 

Erysipelatous  Inflammation— Causes.  Varieties:  1.  Simple;  Symp- 
toms—Treatment: Local— Constitutional.  2.  Phlegmonous;  Pa- 
thology—Treatment  164 


•  •• 

Vlll 


CONTENTS. 

xjivisioisr  II. 

THE  HEALING  PB00K88,  AND  DISEASES  OP  THE  HEALIXO  PROCESS. 

CHAPTER  XX. 

•     *     •     •     t     , 

CHAPTER  XXI. 

Five  Methods    of  Repair-Immediate   Union-Primary  Adhesion-     , 

Granulation-Second  Intention,   or  Second   Adhesfon-Unr~ 

Scab,  Cicatriaation-Requisite  for  Granulation.  i,- 

'        '         •         •         •       177 

CHAPTER  XXII. 

^'''"~^.ll?''t!'^  Healing  Process-Division  of  Ulcers-Causes  of 


Unhealthy  Ulcer-ConstUutional  Causes-Treatment  of  Zlhy 

vlT  7        ^°^'''"^y-^««'^-I'^dolent-Irritable-  Inflamedi 
Phagedenic— Cancer,         .        . 


I3I"V-ISIOlsr    III. 

EXTEBNAL   INJURIES- CONTUSIONS  AND  WOUNDS. 


PAOI 


172 


185 


CHAPTER  XXIII. 

Contusions— Results— Treatment,    . 


192 


11 


CHAPTER  XXIV. 

Wounds-Deflnition-dassification-The  several  Dangers  attending 
Wounds -Incised  Wounds -Characteristics- Gaping -Hemor- 
rhage— Arterial— Natural  Hsemostatics,  .    ^ jg^ 


CONTENTS. 


IX 


CHAPTER  XXV. 


PAOI 


Treatment-General  Indications-To  Arrest  Hemorrhage-Cold  Air- 
Cold  Water-Pressure-Styptics-Escharotics-Nitrate  of  Silver- 
Ligature-Torsion-Acupressure-Conatitutional  Means-Of  Se- 
condary  Hemorrhage— Of  Venous  Hemorrhage,  2OI 


CHAPTER  XXVI. 

2d  General  Indication:  Remove  Foreign  Bodies.  3d:  Close  the  Wound 
and  Retain-Means:  Plasters-Sutures-Twisted  Sutures-Quilled. 
4th:  Prevent  Inflammation, gn 


CHAPTER  XXVII. 

Lacerated  Wounds:  Characteristics-Treatment.    Contused  Wounds- 

Treatment.    Punctured  Wounds :  Characteristics-Treatment,      .      217 

CHAPTER  XXVIII. 

Gunshot  Wounds :  History-Division-Missiles-Velocity-The  Kind 

of  Injury— Position  of  Body— Location  of  Ball,       ....      224 


CHAPTER  XXIX. 

Symptoms   of  Gunshot  Wounds-Treatment:    Local-General-Pri- 
mary, or  Secondary  Operations 


231 


CHAPTER  XXX. 


Poisoned  Wounds-Three  Varieties.-(l)  Dissecting  Wounds-Symp- 

toms— Treatment.— (2)  Stings,  &c \      237 


CHAPTER  XXXI. 

Third  Variety:  Hydrophobia-Two  Kinds-Dog-madness-Symptoms 
-Three  Stages-Symptoms  in  Man-Coih-se-Diagnosis-Patho- 
logy— Period  of  Latency- Prognosis— Treatment, ....      242 


CHAPTER  XXXII. 

Tetanus :  Symptoms-Stages-Pathology-Diagnosis-Treatment, 


256 


B 


CONTENTS. 


IDIVISIOIT     I  v. 


Dlf  EASES   OF   CERTAIN  TISSUES,  BONES,    JOINTS   (INCLUDING    FRACTURES  AND 
DISLOCATIONS),    ARTERIES,   AND   VEINS. 


CHAPTER  XXXIII. 


PAGE 


Diseases  of  Bono :  Hemarks— Classification— Course  to  be  Pursued— In- 
flammation of  Periosteum— Of  Bone— Causes— Synptoms— Local- 
General— Prognosis— Pathology— Terminations— Duration— Treat- 
ment of  Acute — (Jhronic — Of  Products — Fibrin,     ....      262 


CHAPTER  XXXIV. 

Necrosis:  Kinds— Sequestration— Symptoms— Treatment.  Softening  of 
Bono :  Kinds— Rickets— Diagnosis— Treatment.  Hypertrophy  and 
Induration  of  Bone — Atrophy — Causes  of  Each,     .... 


274 


CHAPTER  XXXV. 

Caries :  Pathology— Causes— Symptoms— Diagnosis— Prognosis— Treat- 
ment—General— Local— Operation-Tubercle  in  Bone,   . 


284 


CHAPTER  XXXVI. 

Fractures:  Definition-Causes  — Bones  most  liable— Classification- 
Variety  of  Displacement— Causes-Symptoms  of  Fracture — Diag- 
nosis— Mode  of  Examining — Prognosis, 


290 


CHAPTER  XXXVII. 


Healing  Process  of  Bono:  Pathology— Treatment.  Three  Indica- 
tions: 1,  Restore  Bono;  2.  Retain;  3.  Prevent  Inflammation.  Ap- 
pliances: Bandages — Compresbca — Splints, 


801 


CHAPTER  XXXVIII. 


Treatment  of  Compound  Frnoture:  Irregular  Callus— Causes-Treat- 
ment— Exuberant  Callus — FiiIho  .Joint — Cuuses Treutuient Dias- 
tasis  


ai2 


CONTENTS. 


XI 


.CTURES   AND 


CHAPTER  XXXIX. 


PAOI 


Surgical  Affections  of  Joints — Joints  most  liable — Inflammation — 
Causes — Synovitis — Symptoms  —  Prognosis  —  Pathology — Inflam- 
mation of  outer  Tissues — White  Swelling — Morbus  Coxarius—  Ro- 
sults, 316 


PAOI 


CHAPTER  XL. 

Treatment:  Rest — Applications — Excision,    . 


323 


262 


274 


284 


CHAPTER  XLI. 

Dropsy  of  Joints :  Causes— Treatment.  Elongation  of  Ligaments.  Car- 
tilt  ge  in  Joint:  Diagnosis— Prognosis — Treatment.  Wounds  of 
Joints  :  Diagnosis— Treatment.  Deformities  of  the  Joints :  Va- 
rietios— Congenital— Non-congenital— Treatment,  ....      330 


CHAPTER  XLII. 

Dislocations :  Causes — Classification — Diagnosis — Prognosis  —  Patho- 
logy—Treatment— Indications— Reduce  the  Principal  One— Re- 
move Obstacles — Complications, 340 


290 


CHAPTER  XLIII. 

Surgical  Afiectiono  of  Arteries :  Inflammation— Coagulated  Fibrin  in 
Vessel— Pathf  logy.  Aneurism  :  Divisions— Varieties— Causes- 
Symptoms  and  Di  \gnosi8— Prognosis— Course— Results, 


348 


801 


CHAPTER  XLIV. 

Treatment  of  Aneurisms:  Three  General  Methods— Compression- 
Digital  Compression— Trent  by  Flexion- By  Manipulation— By 
Ligature— By  Hunter's  Metliod— By  Brnsdor's— By  Wftrdroi)'8— 
By  Injections— By  a  Current  of  Electricity.  Varieties;  Vari- 
co80—Arterio-venou8— Treatment.    Aneurism  by  Anastomosis,     . 


358 


ai2 


CHAPTER  XLV. 

Huriricttl  Affootions  of  Veins :   Rumarka,     Th!!>?!itia;  H"rTin*ntr- Trea*- 

ment.    Entrancoof  Air  into  Veins:  Symptoms— Treatment,  . 


3G8 


xu 


CONTENTS. 


i^ivxsioisr   V. 


MORBID   GROWTHS. 


CHAPTER  XLVI. 


PAGE 


Morbid  Growths:  Division-Analogous-Heterologous-Fibrous     Di- 
agnoses-Treatment-Fibroid-Patty-Cartilaginous-Myeloid- 

—Glandular— Vascular— Sarcomatous,     ... 


CHAPTER  XLVII. 

Cancerous  Tumors :  Romarks-In  two  forms-Two  stages-Mlcrosco- 

m'JJTT"-  ^"'''""'^  '^'"'''''-  Colloid-Encophaloid- 
Epithehal-Course-Symptoms-Tcrmination-Effects  upon  con- 
8t:tution  Treatment:  Local  and  Gcneral-E^tirpation-Caustic 
—Congelation- Pressure, ^      ^ 


ERRATA. 

,     r.»a     »ne  applioiUion  of  a  cooling  or  sedative  lotion." 
Pag.  192  9th  line  from  bottom,  instead  of  "the  coats  are  so  lacerated  "  r.a.l  -iH 
vessels  are  so  lacerated."  »  »™  "o  lacerateU,     read  "  the 

Pnge  331,  7th  line  from  bottom,  instead  of  « rally,"  read  "volley." 


PRINCIPLES  OF  SURGERY. 


CHAPTER    I. 


'  not  going 

s 

'3 

ion,"  read 

1 

r  sedativo 

•l 

* 

read  oth* 

i 

INTRODUCTION. 

Nutrition— Development— Growth— Assimilation— The  "Formative  Process" 
—Ordinary  Decay- Repair- Four  conditions  necessary  for  Repair. 

In  the  following  pages,  I  shall  first  treat  of  Inflammation,  dis- 
eases arising  therefrom,  and  its  varieties ;  secondly,  of  the  Healing 
Process ;  thirdly,  of  External  Injuries ;  fourthly,  of  Diseases  of 
certain  Tissues ;  and  fifthly,  of  Tumors,  or  morbid  growths. 

Although  the  inflammatory  process  and  the  healing  process  are 
distinguished  by  a  separate  consideration,  I  shall  endeavor  to  show 
that  healthy  inflammatory  action  is  a  step— a  first  step— in  the 
process  of  healing;  that,  while  healing  more  expeditiously  takes 
place  when  inflammation  is  absent,  yet,  under  certain  circum- 
stances, the  inflammatory  process  is  necessary  to  prepare  the  way 
and  supply  the  means  for  successful  healing.  When,  however, 
the  inflammatory  action  is  unhealthy,  when  there  is  presented 
some  one  of  the  several  varieties  of  inflammation,  then  there  is  a 
de  facto  disease.  The  distinction  between  the  two  will  be  found 
to  be  the  same  as  that  which  exists  between  a  healthy  ulcer  and  an 
unhealthy  one  ;  when,  in  the  former,  healing  kindly  takes  place  in 
accordance  with  physiological  laws,  and  in  the  latter  it  fails  to 
take  place. 

In  order  to  understand  aright  the  phenomena  of  inflammation, 
it  is  necessary  to  bear  in  mind  the  physiology  of  healthy  nutrition 
of  tissues.     It  is  essential  to  understand  what  tak«H  «la«ft  ia  the 


18 


PRINCIPLES    OP    SURGERY. 


ordinary  course  of  life ;  the  manner  in  which  tissues  grow,  are 
developed,  anu  their  natural  integrity  maintained,  notwithstanding 
the  constant  wear  and  tear  of  their  substance.  This  knowledge 
of  physiology  is  requisite,  inasmuch  as  there  is  a  very  close  resem- 
blance between  the  process  of  nutrition  and  the  commencement  of 
inflammatory  action,  and  also  because  of  the  striking  analogy 
between  the  process  of  repair  constantly  going  on  in  the  various 
tissues  and  those  steps  taken  by  nature  to  heal  the  structure  after 
a  solution  of  its  continuity;  and,  furthermore,  because  of  the 
resemblance  between  all  of  the  foregoing  processes  and  those  mor- 
bid conditions  known  as  Hypertrophy  and  Atrophy. 

In   health,   we    have   development,   growth,    and   assimilation. 
These,  together,  may  be  called  the  "  formative  process."    (Paget.) 
While  there  is  a  difference  between  development  and  growth,  yet 
the  two  go  on  generally  together  until  maturity  of  the  body  : 
thus,  in  the  foetus,  development  and  growth  go  hand  in  hand;  also 
in  childhood,  and  up  to  mature  age.     There  is,  however,  this 
manifest  difference  between  the  two,  of  which  the  student  should 
have  a  distinct  understanding :  development  is  not  necessarily  an 
increase  of  substance,  but  an  advancement,— an  elevation  to  a 
higher  state  of  existence  ;  as,  for  instance,  in  the  brain,  the  heart, 
&c.     These  are  gradually  developed  from  the  most  simple  con- 
stituents to  those  of  the  most  complex.     Growth,  on  the  contrary, 
means  merely  an  increase  in  the  bulk,  taking  place  according  to 
certain  general  laws.     When  the  body  is  in  a  state  of  health,  the 
one  process  attends  the  other ;  but  either  may  proceed  without  the 
other  ;  as,  for  instance,  the  brain  may  cease  to  grow  at  any  period 
of  foetal  life,  while  development  continues ;  or  the  reverse  may 
occur ;  that  is,  development  may  be  arrested,  although  growth  is 
continued.  Paget,  in  his  most  useful  work  ("  Surgical  Pathology"), 
refers  to  two  specimens :  "  Among  the  malformations  in  the  mu- 
seum of  St.  Bartholomew's  Hospital,  arc  the  brains  of  two  adult 
idiots.     They  are  equally  diminutive,  and  of  nearly  equal  size : 
but  in  one,  so  far  as  we  can  see,  there  is  a  due  proportion  of  the 
several  parts ;  it  is  only  too  small :  in  the  other,  the  parts  are  not 
well  proportioned ;  the  posterior  parts  of  the  cerebrum  do  not  half 
cover  the  cerebellum ;  indeed,  no  posterior  cerebral  lobes  appear 
to  be  formed.    Herein  wo  recognize  something  more  than  a  checked 
growth ;  for  this  truncation  of  the  cerebrum  indicates  an  arrest  of 


INTRODUCTION. 


19 


its  development  at  the  lime  when  its  hinder  lobes — the  parts  last 
produced,  and  peculiarly  characteristic  of  the  human  brain — 
were  only  just  beginning  to  be  formed.  Our  explanation  of  this 
most  interesting  specimen  must  be,  that,  when  the  brain  had  at- 
tained that  degree  of  development  which,  according  to  Professor 
Retzius,  is  proper  to  the  human  foetus  about  the  beginning  of  the 
fifth  month,  and  corresponds  with  the  completed  development  of 
the  brain  of  lower  mammalia,  then  its  development  ceased.  But 
though  in  form  it  is  like  the  foetal  brain  in  the  fifth  month,  yet, 
in  all  its  dimensions,  it  is  larger  ;  so  that,  although  its  develop- 
ment had  ceased,  its  growth  continued,  and  was  not  checked  till 
the  brain  had  attained  the  size  of  that  of  a  mature  foetus.  In 
this  brain,  therefore,  we  find  at  once  defective  development  and 
defective  growth ;  but  in  the  other,  the  development  proceeded, 
and  the  growth  alone  was  checked."  On  the  other  hand,  examples 
in  which  development  was  checked  while  growth  continued,  may 
be  seen  in  malformed  hearts,  where  only  a  single  cavity  exists,  no 
partition  having  been  developed ;  yet  where  growth  proceeded  in 
regular  order. 

At  all  periods  of  life  decay  in  the  body  is  going  on.  Every 
living  body,  everything  indeed  in  all  animated  nature,  has  a  lim- 
ited period  of  life — has  a  period  of  growth,  maturity,  and  decay ; 
and  so  it  is  in  the  human  body.  Not  only  the  body  as  a  whole 
has  its  period  of  existence  terminating  in  death,  but  every  parti- 
cle of  tissue,  every  element  which  enters  into  the  formation  of  the 
whole,  has  its  own  limit  of  life.  It  is  begotten,  it  matures,  it  fades, 
it  dies.  This  is  independent  of  the  life-course  of  the  whole  frame. 
And,  from  the  earliest  period  of  embryonic  life  until  the  heart 
finally  ceases  to  beat,  this  process  of  limited  life  in  the  tissues  is 
constantly  being  enacted.  Paget  gives  two  sources  of  decay  in 
the  tissue,  or,  as  it  is  aptly  expressed,  of  "wear  and  tear,"  one 
of  which  is  exercise,  and  the  other  natural  death,  in  accordance 
with  a  general  law. 

After  growth  and  development  are  completed,  assimilation — a 
process  coeval  with  the  life  of  the  body — is  the  only  remaining 
way  by  which  the  "  formative  process"  is  manifested.  In  passing, 
I  may  just  state  that  these  worn-out,  or  dead  particles,  are,  when 
the  body  is  in  a  state  of  health,  duly  removed  from  the  system — 
excreted  by  some  one  or  more  of  the  excretory  organs ;  or  it  may 


.# 


m 


20 


PRINCIPLES    OP    SURGERY. 


be,  acoordmg  to  the  view,  of  some  recent  writer,,  th.t  eome  of 
Iheir  elements  enter  into  new  combinationa  and  continue  to  serve 

1  ko^  ^  '"  "  "7  "T":?-  '^^'  °°»»'it"e"t«  of  some  tissues  of 
the  body  are  endowed  wth  a  more  protracted  life  than  those  of 
oth  rs ;  .ndeed,  the  function  of  some  tissues  is  such  that  removal  of 
effete  matter  and  repair  cannot  with  readiness  conveniently  take 

'r:;e:e"rve;r°  "^  Tr"""'^'-"™'""''^'""'"'  *»-  «-' 

are  preserved  from  speedily  wearing  ont-as  the  cartilages  of  the 
jom  s  hgamcnts,  tendons  of  muscles,  &c.    It  is,  then,  a  physiolo 
g.cal  law,   hat  some  tissues  should  be  more  mutable  than  0^. 
bu  ,  more  than  th.s,  any  one  tissue  may  be  rendered  sbort-1  ved  by 
unnatural  weakness,  which  weakness  may  have  primarily  existed 
or  subsequently  have  been  acquired ;  that  is  to  say,  a  system  or  an 
.nd,v,dual  fssue,  perfectly  sound,  will  live  and  weir  longe"'unde; 
the  same  circumstances,  than  one  which  is  defective.     There  is  a 
close  hkeness  between  this  life  of  individual  tissues,  and  the  bebg 
wh,ch    hey  together  compose.     As  every  living  being  beget,  off 
epnng  hke  unto  .tself,  so  the  constituents  in  their  mint  life  cease 
only  to  hve,  when  other  similar  ones  are  begotten  and  prepared  to 
succeed  them  m  the  part  they  have  played.    It  is  this  pr  ee  s 
wh,eh  ,s  called  assimilation.     This  question,  however  interes  nT 
canno  here  be  further  discussed ;  for  a  com'plete  consider  tCff 
b  sulyect  the  reader  ,s  referred  to  Pagefs  "  Surgical  Pathology,"' 
and  Virohow's  "  Cellular  Pathology."  ^ 

Bat  not  only  does  every  elementiry  structure  in  the  body  decay 
•nd  d,e;  „,  as  well,  under  certain  morbid  influences,  de.erLates! 
or  degenerates-becomes  changed  in  its  essential  character  in 
consequence  of  which  it  is  incapacitated  for  a  proper  discharg^  of 
Its  duties ;  just  as  the  whole  body  may,  as  the  result  of  disease!  be- 
come  unfit  to  act  its  part  aright. 

We  have  now  learned  that,  when  the  body  is  in  a  state  of  health, 
.  all  periods  of  life  there  is  a  constant  loss  being  sustained  by  th 
eementary  structure  of  the  body,  in  some  of  which  the  loss  is 
rapid,  and  in  others  tardy  ;  yet  invariably  taking  place.  Now  if 
the  integrity  of  the  body  is  to  be  maintained,  repair  must  be  mldc 
n  tl  e  same  proportion  a,  there  is  loss.     This  repair  is  known  by 

show  the  close  connection,  or  resemblance,  perhaps  I  might  say 


INTRODUCTION. 


21 


identity,  of  this  process  and  that  generally  known  as  the  Healing 
Process.     Of  this  I  shall  more  particularly  speak  hereafter. 

At  present  let  us  glance  at  the  "  conditions"  which  are  neces- 
sary to  the  efficient  repair  of  every  part  of  the  body,  so  constantly 
being  made,  and  for  the  successful  carrying  out  of  which  we  find 
nature  so  fully  adequate.  And  I  cannot  do  better  than  to  give 
Paget's  own  words.  "  Doubtless,"  he  says,  "  the  conditions  neces- 
sary to  the  normal  nutrition  of  parts  are  very  many ;  but  the  chief 
of  them  are  these  four : 

"  1.  A  right  state  and  composition  of  the  blood,  or  rather  nutri- 
tive material. 

"  2.  A  regular  and  not  far  distant  supply  of  such  blood. 
"  3.  (At  least  in  most  cases)  a  certain  influence  of  the  nervous 
system. 

"4.  A  natural  state  of  the  part  to  be  maintained." 
With  regard  ta  the  first.  A  builder,  if  he  wish  to  have  a  per- 
feet,  a  time-enduring  edifice,  will  endeavor  to  procure  good  sound 
material  for  its  construction  ;  and  so  it  is  with  respect  to  repair  of 
tissue.  To  secure  a  continuance  of  health  in  the  physical  frame 
there  must  be  a  healthy  condition  of  the  blood— that  fluid  which 
streams  to  and  from  every  part  of  the  body,  and  whose  current 
carries  thereto  the  elements  of  nutrition,  and  therefrom  those  which 
have  ceased  to  be  tissue. 

The  second  condition  is,  there  must  be  a  regular  supply  of 
such  blood— not  too  much,  not  too  little— at  all  times  the  same,  to 
every  tissue  according  to  its  necessities.  It  is  the  bread  of  life  to 
the  tissue,  and  the  demand  is  imperative.  If  a  tissue  be  not  regu- 
larly supplied  with  blood,  disease  will  result.  On  the  one  hand,  if 
there  be  too  little  blood  for  a  length  of  time,  atrophy  will  follow ; 
or,  should  it  be  entirely  cut  off",  mortification  will  ensue.  On  the 
other  hand,  where  too  much  blood  exists  in  a  part,  it  constitutes 
congestion,  which  may  lead  to  inflammation ;  or  a  long-continued 
congestion  may  give  rise  to  hypertrophy.  These  two  diff^erent 
results  of  hyperemia  may  depend  upon  other  circumstances ;  but 
here  can  only  bo  explained  that  a  mdden  influx  of  blood  to  a  part 
is  likely  to  produce  inflammation,  while  a  gradual  and  limited 
increase  is  more  likely  to  be  followed  by  hypertrophy.  The  power 
of  assimilation  belongs  to  every  tissue  ;  it  is  a  law  of  life.  After 
the  body  is  fully  grown  the  extent  of  assimilation  in  health  will 


22 


PRINCIPLES    OP    SURGERY. 


depend  upon  the  amount  of  decay,  otherwise  the  natural  condition 
will  not  be  maintained.  It  would  seem  that  a  redundant  supply  of 
arterial  blood,  long  continued,  may  cause  the  tissue  thus  supplied, 
to  assimilate  to  a  greater  extent  than  there  is  wear  and  tear ;  the 
result  of  which  will  be  hypertrophy. 

The  third  requirement  for  ordinary  repair  of  tissue  is  a  certain 
nervous  influence.  Assimilation  may  possibly  continue,  although 
imperfectly  for  a  time,  notwithstanding  the  nervous  influence  is 
witndrawn ;  but  very  soon  after  its  withdrawal  the  tissue  will  ex- 
hibit signs  of  impairment.  Examples  of  this  is  often  seen  where 
nerve-trunks  have  been  injured,  or  are  pressed  upon  by  a  morbid 
growth.  The  tissue  to  which  this  nerve  is  distributed  seems  inca- 
pable of  propagating  itself.  The  absence  of  the  nervous  supply 
may  prevent  the  normal  circulation  of  nutritious  fluid.  At  all 
events  the  result  is  atrophy  of  the  structure. 

The  fourth  condition  necessary  is  a  natural  condition  of  the  part 
to  be  maintained  in  a  state  of  repair.  Now,  if  a  part  has  been 
originally  healthy,  and  the  three  previously  stated  conditions  be 
continually  present,  this,  the  fourth,  will  never  be  absent.  If, 
however,  the  structure  have  been  originally  abnormal  or  weak, 
then,  although  the  three  conditions  mentioned  be  not  wanting,  the 
fourth  will  not  exist.  Again,  as  has  been  stated,  if  one  or  more 
of  the  first  three  conditions  be  absent,  it  will  result  in  a  want  of 
the  fourth — that  is,  if  the  blood  is  not  pure  in  composition,  or  if 
it  is  not  regularly  supplied  to  a  part,  or  if  there  be  a  want  of 
nervous  influence,  there  will  soon  be  an  abnormal  state  of  the 
tissue,  so  as  to  render  it  incapable  of  assimilating,  even  although 
the  other  conditions  had  been  restored. 

It  does  not  come  within  the  scope  of  this  work  to  do  more  than 
allude  to  the  physiological  necessities  to  secure  the  above-men- 
tioned requisites  for  repair  of  the  constantly  wearing-out  tissues 
of  the  body.  In  the  first  place,  as  already  intimated,  a  healthy 
constitution  is  a  prerequisite  ;  then  there  must  be  a  natural  volume 
of  healthy  blood,  which  must  be  maintained  in  its  purity  and  ful- 
ness of  quantity.  In  order  to  this,  proper  food,  properly  taken, 
followed  by  healthy  digestion,  and  formation  of  blood,  are  essen- 
tial. It  is  well  to  remember  that  chyle,  just  entered  into  the  cir- 
culating blood,  is  not  itself  blood,— that  changes  of  a  vital  nature 
have  to  take  place  before  it  can  enter  upon  the  high  duty  which  it 


INTRODUCTION. 


28 


is  intended  to  perform.  This  crude  material  has  to  undergo  a 
process  of  development.  The  blood,  like  the  solid  constituents  of 
the  body,  is  developed  and  grows.  Within  the  blood-mass  there 
is  constantly  to  be  found  development,  maturity,  and  decay;  and 
the  worn-out  portion  of  blood  is  quite  as  much  an  eflFete  material 
as  those  of  the  tissues.  Consequently,  where  anything  interferes 
with  any  one  of  the  natural  processes  of  blood  development,  there 
will  be  an  imperfectly  elaborated  pabulum  for  the  wasting  tissues. 

Again,  it  is  necessary  that  eflFete  matter  should  be  eliminated 
from  the  blood, — those  elements  which  can  no  longer  serve  any 
purpose  in  the  physical  economy.  These  products  of  decay  are 
constantly  forming,  and  an  eflScient  state  of  the  excretory  organs 
is  demanded.  In  the  venous  blood  are  found  elements  which  are 
poisonous  in  their  effects  when  not  duly  removed,  and  which  are 
separated  from  the  blood  in  the  lungs  by  the  substitution  of  oxygen. 
To  insure  this,  a  sound  state  of  the  lungs  and  pure  air  are  required. 
When  effete  material  is  not  excreted,  proper  development  of  the 
blood  cannot  proceed,  and  assimilation  in  the  tissues  is  disturbed, 
or  perhaps  impossible.  Moreover,  their  retention  may  be  the 
source  of  a  poison  more  or  less  destructive  to  the  system,  as  in  the 
non-excretion  of  carbonic  acid  and  of  urea. 

If  these  functions  of  life  referred  to  be  quite  normal,  then  the 
blood  will  be  preserved  at  its  natural  standard, — will  be  duly  fitted 
to  repair  wasted  tissue  in  every  part  of  the  body.  If  not,  then 
disease  of  some  kind  will  surely  arise. 

In  concluding  this  chapter,  it  may  be  stated,  in  connection  with 
the  foregoing,  that,  in  order  to  have  the  healing  process,  hereafter 
to  be  described,  successfully  carried  on,  the  same  conditions  and 
the  same  prerequisites  are  equally  necessary ;  and  it  is  because 
such  is  the  case,  as  well  as  because  of  the  close  resemblance  be- 
tween ordinary  repair  of  tissue  and  that  which  we  may  call  extra- 
ordinary repair,  where  there  is  a  palpable  breach  of  tissue,  that  it 
has  been  deemed  desirable  to  take  this  brief  survey  of  these  few 
physiological  truths.  And  although  a  knowledge  of  inflammation 
may  be  acquired  without  having  previously  studied  these  points, 
the  task  would  be  less  easy,  the  labor  greater,  the  result  less 
satisfactory. 


r,  . 


mPLAMMATIOX,  AND  DISEASES  ARISINa  OUT  OE  INFLAMMATION. 

CHAPTER   II. 

Inflammatory  Process-Incubation-Coneestion     Tr.fl<.™      .•      t, 

st.,n..,.n-c..„,.  <n  Blood jr„rcr;rr„.r"'"'^^ 

Tvaste  and  decay  in  the  nart      Y.IT  ^    '  *^'  ^"^^"^^^ 

l,n  .ff    *  J  •   ^       ,     P  ^®*  *^^^  increase  of  structure  w.Il 

creased  d„t.     It  would  see™  that  th'e  incta  eT  «'  ™  :;:;"; 

principle,  which  are  basf/'upof  t'^Td ll'e  "„?  tt  ^'^n"; 
neuro-pathologirts,  without  adducing  the te    v Lw    ^  f    "^ 
^u„d  e,nbraced  in  the  doctrine  of  cf.lular  piho  ogT;  ZlZ 
allow  Virchow  to  speak  for  himself.    He  savs  na<re  Iss    °  Tf 
we  proceed  with  our  analysis  of  wh,t  L  tU     ,  ^  T         " 


ilr^f 


'AMMATION. 


DISEASES    ARISING    OUT    OP    INFLAMMATION.  25 

will  greatly  assist  you  in  the  classification  of  pathological  condi- 
tions, and  because  it  is  not  wont  to  be  set  forth  with  particular 
distinctness. 

"  When,  namely,  a  given  action  is  called  into  play,  we  have  to 
deal  with  a  manifestation  either  of  the  function,  the  nutrition,  or 
the  formation  of  a  part.     It  certainly  cannot  be  denied  that  at 
certain  points  the  boundaries  between  these  different  processes 
disappear ;  and  that  between  the  nutritive  and  formative  processes, 
and  also  between  the  functional  and  nutritive  ones,  there  are  trans' 
itional  stages ;  still,  when  they  are  typically  performed,  there  is 
a  very  marked  difference  between  them;  and  the  internal  changes 
which  the  individual  excited  part  undergoes,  according  as  it  only 
performs  its  functions,  or  is  subjected  to  a  special  nutrition,  or 
becomes  the  seat  of  special  formative  processes,  exhibit  consider- 
able differences.     The  result  of  an  excitation,  or,  if  you  will,  an 
irritation,  may,  according  to  circumstances,  be  either  a  merely 
functional  process,  or  the  effect  may  be  that  a  more  or  less  in- 
creased  nutrition  of  the  part  is  induced  without  there  necessarily 
bemg  any  excitation  of  its  functions ;  or  a  formative  process  may 
set  in,  giving  rise  to  a  greater  or  less  number  of  new  elements. 
These  differences  manifest  themselves  with  greater  or  less  distinct- 
ness, in  proportion  as  the  individual  tissues  of  the  body  are  more 
or  less  capable  of  responding  to  the  one  or  other  kind  of  excita- 
tion." 

Again,  he  says :  "  You  will  be  able  to  gather,  from  what  I 
have  communicated  to  you,  that  nowadays  it  can  no  longer  be 
said,  with  any  show  of  reason,  that  the  nerves  alone  are  irritable 
parts,  but  that  we  are  irresistibly  led  to  consider  functional  irri- 
tability at  least  as  a  property  belonging  to  whole  series  of  organs. 
Far  less  known,  gentlemen,  is  that  clearly  demonstrable  series  of 
processes  in  which  nutritive  irritability/  manifests  itself— that  power 
possessed  by  individual  parts  of  taking  up,  when  excited  by  defi- 
nite  stimuli,  more  or  less  matter,  and  transforming  it." 

From  this  it  will  be  seen  that  the  important  an*d  exclusive  part 
which  the  nerves  have  hitherto  been  supposed  to  play  with  rec^ard 
to  hypertrophy,  and  also  to  inflammation,  is  not  unquestioned. 
Indeed  it  is  almost  apparent  that  the  views  formerly  held  in  this 
as  well  as  in  other  particulars,  will  have  to  be  materially  modified. 
The  nervous  distribution  throughout  the  body  cannot  be  said  to 


26 


PRINCIPLES    OF    SURaBRT. 


be  general.  Tracing  the  nerves  to  their  final  peripheral  termina- 
tions,  it  is  found  that  there  are  spaces  into  which  no  nerve  is  seen 
to  enter,  although  this  district  seems  to  be  none  the  less  endowed 
with  sensibility. 

Again,  in  cartilage  no  nerves  are  found,  yet  the  articular  car- 
tilage is  not  exempt  from  a  high  degree  of  sensibility.  That  the 
nerves  have  much  to  do  in  the  various  pathological  effects  of  irri- 
tation,  cannot  be  doubted ;  but  it  seems  equally  certain  that  the 
various  tissues,  when  irritated,  exhibit  phenomena  which  are  solely 
dependent  upon  powers  residing  within  themselves,— a  result  of 
vitality  belonging  to  the  cellular  constituents  of  the  parts.  This 
digression  was  necessary  to  a  clear  appreciation  of  the  phenomena 
of  inflammation. 

The  effect  made  upon  a  part  by  a  stimulus  is  soon  transmitted 
to  the  nerves ;  and,  according  as  this  is  great  or  long  continued, 
It  extends  along  the  nerves  to  parts  farther  removed  and  to  nerve- 
centres.    Now,  when  the  excitation  is  limited  in  degree,  the  result 
will  not  exceed  the  bounds  of  health  (physiological  stimulus) ;  but 
when  the  stimulus  extends  beyond  this,  then  the  result  will  be  of  a 
morbid  nature  ("  pathological  irritant").     These  results,  so  widely 
different  when  attained,  are  both  reached  by  steps  at  first  identical, 
and  afterwards  very  similar.     When  a  part  is  irritated,  whether 
originating  in  the  nerves  or  other  tissue,  the  effect  thereof  is  not 
confined  to  that  part,  but  it  soon  makes  known  to  other  parts  the 
fact  that  it  is  disturbed.     Information  is  given  by  the  nerve  with 
electric  speed;   the  message  is  carried  to  a  nervous  centre;  it 
almost  seems  as  if  the  electrical  disturbance  radiated  from  the 
point  affected ;  and  that,  as  it  extended  along  the  nerve-cord,  it 
gradually  lessened,  until  it  finally  ceased.     In  accordance  with 
some  law,  perhaps  not  yet  fully  determined,  there  is  a  reflex 
nervous  action,  the  result  of  which  is  an  influx  of  blood ;  there  is 
at  once  an  increased  activity  manifested  in  the  part.     In  the  ca  j 
of  unusual  exercise  of  an  organ,  this  increaboJ  supply  of  blood  is 
plainly  a  response  to  the  call  for  more  blood  to  increase  the  cii- 
ciency  of  the  organ.     If,  however,  the  irritation  be  of  an  injurious 
nature,  the  increase  of  blood  seems  to  be  intended  to  supply  means 
either  for  expulsion  of  the  irritating  cause,  or  to  limit  its  effects. 
The  blood  flowing  in  greater  quantity  t^     'le  part  finds,  up  to  a 
certain  point,  incrvas-^'f  accorjimodation ;  the  smaller  arteries  and 


DISEASES    ARISING    OUT    OP    INFLAMMATION. 


27 


the  capillaries  are  increased  in  calibre,  so  as  to  allow  the  blood  to 
flow  through  the  part.  The  blood  continuing  thus  to  flow  for  a 
time,  there  may  be  exaltation  of  function,  or  nutrition,  or  a  new 
formation ;  that  is  to  say,  if  a  gland  be  the  seat  of  congestion,  its 
function  may  be  increased,  or  it  may  become  larger  by  increase 
of  its  natural  substance,  or  a  new  formation  may  result.  But 
should  the  irritation  exceed  a  certain  degree,  then  other  and  dif- 
ferent efl"ect3  will  follow 
the  congestion.  The  blood 
rushing  to  the  part,  or  at- 
tracted to  the  part,  past  a 
certain  d(  gref ,  seems  to  in- 
duce a  contraction  of  the 
Tci!!t3ol-:) ;  and  here  way  he 
considered  the  turning-point, 
the  dividing  line  bettveen  phy- 
siological and  'pathological 
action.  The  coats  of  the 
vessels,  distended  and  irri- 
tated beyond  their  power  to 


bear,  strive  to  resist  the 
overflowing  blood  and  con- 
tract with  spasmodic  energy, 
and  there  is  at  once  a  dis- 
turbance of  those  conditions 
necessary  for  healthy  nutri- 
tion. The  vessels  under  the 
great  irritation,  after  having 
been  dilated  to  their  fullest 
normal  extent,  spring,  as  it 
were,  to  recover  themselves ; 
and,  like  a  muscle  pierced 
b^  ci  spicula  of  bone,  or  the 
urethra  irritated  by  a  mor- 
bid urine,  cease  for  the  mo- 
ment to  be  controlled  by  or- 
dinary nervous  power  and  spasmodically  contract,  and  to  such  a  de- 
gree that  the  calibre  of  the  vessels  is  reduced  below  the  natural  size. 
The  spasm,  however,  is  of  limited  duration,  and  is  succeeded  by 


Irregular  contraction  of  small  vessels  from  the  web 
of  a  frog's  foot  after  the  application  of  stimuli.  Copied 
fVom  Wharton  Jones. 


It  ;; 


■  H 


U: 


If' 


^      •■\ 


28 


PRINCIPLES    OF    SURGKRY. 


dilatation.     This  dilatation,  unlike  that  which  primarily  took  place, 
18  the  result  of  morbid  action  and  a  want  of  natural  power  in  the 


coats  themselves.  After  an  uncertain  period  of  time  the  dilata- 
tion is  followed  by  a  second  irregular  contraction,  the  duration  of 
which  is  shorter  than  the  first.  Again,  dilatation  succeeds,  which  is 
ever  becoming  greater,  and  characterized  by  a  continued  decrease 


nacruna  ooDtrutlni  the  natural  and  the  atimulatfil  noiidltioDi  In  a 

oftbe  bat's  wing.  (TaKet.) 


Ulinnnnt  nt  thm  mm 


DISEASES    ARISING    OUT    OP    INFLAMMATION. 


29 


of  power  and  ability  to  contract  in  the  coats ;  yet  a  third  contrac- 
tion may  occur  before  the  vessels  are  entirely  overcome  and  para- 
lyzed. Ultimately,  however,  this  is  the  result.  At  any  period 
during  the  time  these  phenomena  are  being  presented,  if  the  irri- 
tation be  increased  or  varied,  it  is  said  the  contraction  will  be 
greater  than  it  otherwise  would  be.  (Paget's  experiments  on  the 
wing  of  the  bat,  a  warm-blooded  animal.)  When  the  power  to 
contract  ceases  in  the  coats  of  the  vessels,  then  there  is  established 
a  decidedly  morbid  condition.  Already  a  most  important  step  has 
been  taken  in  the  "inflammatory  process." 

In  speaking  of  the  above  phenomena  resulting  from  conges- 
tion, I  have  use<l  the  term  vessels;  because,  and  contrary  to  a 
commonly  received  opinion,  in  the  capillaries  they  are  not  the  most 
perfectly  manifested.  "  A  capillary  vessel  is  a  simple  tube,  which 
we  have,  with  the  aid  of  our  present  appliances,  hitherto  only 
been  able  to  discover  a  simple  membrane,  beset  at  intervals  with 
flattened  nuclei."  "  It  is  this,  the  most  simple  class  of  vessels, 
which  we  nowadays  solely  and  exclusively  call  capillaries,"  "and 
with  regard  to  them  we  cannot  say  that  they  become  wider  and 
narrower  by  means  of  any  action  of  their  own,  but  at  most  that 
their  elasticity  renders  a  certain  degree  of  contraction  possible. 
Nowhere  are  there  to  be  witnessed  in  them  genuine  processes  of 
contraction  or  relaxation  succeeding  it."  (Virchow.)  But  the  im- 
portant fact  remains,  that  every  vessel,  whether  classed  under 
small  arteries,  small  veins,  or  capillaries,  does,  under  irritation, 
whether  it  be  physiological  or  pathological,  contract :  in  the  ab- 
sence of  muscular  fibre  the  contraction  may  be  momentary  and 
evanescent,  but  it  always  takes  place  before  relaxation  and  dilata- 
tion. Consequently  the  less  the  power  to  contract  the  more 
speedy  the  paralysis,  or  total  absence  of  power  to  contract. 

Contuiuing  to  trace  the  inflammatory  process,  let  us  now  exa- 
mine in  what  way  and  to  what  extent  the  contents  of  the  blood- 
vessels  are  aflecied  by  this  seeming  paralysis  of  the  coats.  Re- 
serving for  a  subsequent  occasion  a  more  minute  description  of 
the  changes  which  take  place  in  the  blood  of  the  part,  and  in  the 
circulation  generally,  in  consequence  of  inflammatory  action,  I 
wish  here  to  point  out  only  those  immediate  changes  which  occur 
in  the  blood  occupying  the  paralyzed  vessels.  In  health,  the 
J .  vMi-.-ugu  luc  cuiaiivi-  vcssula  wunout  impeaimentj  liie 


W  PRINCIPLES    OP    SURGERY. 

red  corpuscles  occupying  the  centre  of  the  channel,  the  white 
corpuscles  rather  pressing  against  the  coats  of  the  vessel,  and 
being  less  certain  in  their  onward  movement.  The  nutrient  mat- 
ter transudes  through  the  capillary  coats  with  sufficient  readiness 
to  supply  pabulum  for  the  tissue.  When  there  is  a  physiological 
stimulus,  and  relaxation  of  the  coats  succeeds  a  transient  con- 
traction, their  exalted  nutrition,  as  we  have  seen,  may  be  expected 
to  follow.  When  there  is  truly  a  pathological  irritation,  and  a 
more  complete  relaxation  results,  then  there  seems  to  be  a  larger 
quantity  of  material  transuded  tli  in  can  be  appropriated  by  the 
tissues;  and  now,  not  only  is  there  an  increased  amount,  but  the 
material  is  changed  in  character ;  perhaps  it  is  more  crude  in  its 
composition,  and  unfit  for  nutrition ;  or  it  may  be  the  tissue, 
affected  by  the  disease,  is  incapable  of  exerting  any  influence  over 
the  material  transuded. 

As  the  coats  become  more  and  more  relaxed,  and  finally  lose 
their  power  to  contract,  the  quantity  transuding  correspondingly 
increases.  Now,  it  is  a  question  whether  the  material  which, 
under  such  circumstances,  passes  through  the  coats  of  the  capil- 
laries, is  identical  in  character  and  in  quality  with  that  which 
constitutes  the  tissues'  aliment  in  health. 

The  exact  chemical  constituents  of  the  nutritious  juice  which 
transudes  in  health,  and  which  is  taken  up  by  the  cellular  struc- 
ture, according  to  Virchow,  and  becomes  tissue,  has  not  been 
determined.  The  opinion  long  prevailed  that  fibrin  constituted 
this  material ;  but  there  are  insurmountable  difficulties  in  the  way 
of  continuing  to  regard  it  as  so  high  a  product.  Rather  must  it 
be  conceded  that  it  bears  evidence  of  being  a  material  which  is  in 
the  decline  of  life.  The  total  of  the  fluid  which  transudes  in 
inflammation  is  called  liquor  sanguinis,  and  is  composed  of  serum 
and  fibrin. 


p 


DIAQRAM     OF    BLOOD, 

Chemical  Components. 

■  Water. 

Various  bhUb. 

O 

Fatty  mattors. 

Semm. 

o 

>■ 

Lupmr 

Extractivo  do. 

o 

Sanguinis. 

Albumen. 

^■4 

Fibrin. 

■1^ 
0 

Red  Corpuscles 

Crassa- 
^  mentum. 

Colorless  Corpuscles. 

s 

Granules. 

J 

p 

DISEASES    ARISING    OUT    OP    INFLAMMATION. 


31 


Now,  may  it  not  reasonably  be  supposed  that  the  fibrin,  thus 
placed  without  the  capillaries,  and  unable  to  enter  into  the  forma- 
tion of  tissues,  either  on  account  of  its  own  beginning  metamor- 
phosis, or  the  inability  of  the  tissue  to  appropriate  it,  or  perhaps 
both,  and  having  thus  been  turned  aside  from  the  high  position 
for  which  it  had  been  intended,  assumes  a  new  position  in  respect 
to  its  vitality,  and  its  capability  of  acting  any  part  in  the  opera- 
tions of  life  in  the  system.     Although  it  has,  on  account  of  cir- 
cumstances, apart  from  its  own  developnlent,  failed  in  fulfilling  its 
primary  destiny,  it  constitutes  a  no  less  useful  material.    Although 
it  may  not  act  a  part  in  ordinary  repair  of  tissue,  it  serves  a  pur- 
pose quite  as  important  and  indispensable,  in  effecting  extraordinary 
repair.    The  elements  of  the  blood  which  would,  had  not  the  natu- 
ral functions  been  disturbed,  have  become  tissue,  deviate  from  this 
natural  course  of  development  and  become  the  agent  of  the  healing 
process.     The  nature  of  this  change  is  not  uncertain ;  there  is  not 
only  a  change,  but  a  degeneration— a  descent  from  one  state  of 
existence  to  another.     It  is  a  retrograde  development.     Here  the 
question  as  to  nature  and  oflSce  of  fibrin  of  the  blood  in  healthy 
might  with  propriety  be  discussed ;  but  it  will  be  more  appropri- 
ately  done  in  connection  with  the  subject  of  healing.     I  will  here 
simply  venture  the  statement,   that  the  object  for  which  fibrin 
exists  in  the  blood  is  to  heal,    or  effect  extraordinary  repair. 
That  it  is  a  material  limited  in  quantity,  which  is  kept  in  store 
for  that  purpose,  and  which  is  always  found  to  increase  rapidly  in 
quantity,  and  become  more  efficient  in  quality,  when  a  demand  for 
it  is  made.    The  varied  ways  in  which  it  is  employed  will  hereafter 
be  duly  considered,  as  well  as  the  grounds  upon  which  this  belief 
is  based. 

Here,  then,  is  a  substance  called  liquor  sanguinis,  transuding, 
in  consequence  of  the  morbid  irritation,  which  has  resulted  in 
overdistension  of  the  vessels'  coats.  The  fibrin  of  this  compound 
is  altered  in  character.  It  differs  from  natural  fibrin  in  being 
more  higiily  vitalized.  It  has  degenerated  from  nutrient  material ; 
but  it  constitutes  a  higher  typo  of  fibrin  than  that  which  exists 
ordinarily  in  the  blood.  Derived  from  lusty  elements  which  had 
been  elaborated  for  nutrition,  and  suddenly  exposed  to  conditions 
which  caused  an  early  degeneration,  there  results  a  higher  typo  of 
fibrin,  in  which  is  manifested  that  high  degree  of  vitality  wliinh,  it 
will  be  seen,  is  so  essential  to  a  speedy  restoration  of  the  diseased 


:|^    i 


i*i  I 


I! 


i 


82 


PRINCIPLES    OP    SURGERY. 


part.  This  fibrin  is  more  plastic  than  the  natural ;  and,  not  un- 
likely, this  plasticity  assists  in  delaying  the  ultimate  stagnation  of 
the  blood  in  the  vessels,  to  which  there  is  a  tendency  thereafter. 

The  cau8e  of  stagnation  of  blood  is  another  vexed  question. 
While  the  state  of  paralysis  was  being  reached,  the  flow  of  blood 
was  becoming  more  and  more  tardy,  and,  finally,  after  oscillating 
in  the  vessel  for  a  brief  time,  as  if  trying  to  force  its  way,  it 
ceased  to  move — it  was  stagnant.  The  explanation  of  this  has 
been  sought  by  many  investigators,  and  each  of  the  individual 
elements  of  the  blood  has  enjoyed  the  credit  of  being  the  cause, 
or  one  of  the  causes.  Thus  the  white  corpuscles,  it  is  asserted 
by  some,  although  strenuously  denied  by  others,  are  increased  in 
number,  and  in  consequence  of  their  crowding  against  the  coats  of 
the  vessels  they  increasingly  adhere,  until  the  whole  stream  is  in- 
terrupted. Again,  the  red  corpuscles,  it  is  thought,  show  an  un- 
natural tendency  to  run  together  in  the  form  of  rouleaux,  and  in 
that  way  adhere  together,  as  they  are  seen  to  do,  in  blood  taken 
from  the  system  even  of  a  healthy  person. 


A.  Htcroscopleal  appearance  of  henlthj  blood,    n.  Illood  of  a  patient  aufferlng  from  acute  rhenma. 

tiam  or  inflammation.  (Paget.) 

With  regard  to  the  white  corpuscles,  whether  they  in  any  way 
take  a  part,  it  is  asserted  by  Paget,  II.  Bennet,  Wharton  Jones, 
and  others,  that,  inasmuch  as  the  white  corpuscles  cannot  be  sepa- 
rated from  the  fibrin,  no  positive  evidence  can  be  advanced  in  sup- 
port of  that  theory.  This  view  is  opposed  by  Williams  ("  Princi- 
ples") and  by  Virchow.  Moreover,  it  has  been  observed  that  in 
those  cases  where  the  white  corpuscles  are  in  excess,  the  individual 
was  otherwise  unhealthy.     And  still  more,  these  corpuscles  are 


DISEASES    ARISING    OUT    OP    INFLAMMATION. 


33 


i^m  Mute  rhenm»- 


relatively  increased  in  pregnant  women,  and  in  those  with  tubercu- 
losis, and  in  ill-fed  persons. 

That  the  fibrin  acts  a  very  important  part  in  effecting  the  stag- 
nation in  inflammation,  there  is,  I  believe,  a  general  belief;  but 
in  what  way  is  not  quite  so  certain.  Increased  in  plasticity,  it 
may,  by  adhering  to  the  walls  externally,  tend  to  induce  paralysis 
of  the  capillary  coats.  Again,  it  may  be  that,  at  least  in  some 
cases,  the  fibrin  coagulates  around  the  canal,  and  by  contracting 
in  places  arrests  the  onward  flow  of  the  blood.  But,  as  will  be 
seen  hereafter,  coagulation  generally  does  not  quickly  take  place 
in  the  tissue  under  these  circumstances;  indeed,  the  increased 
vitality  already  said  to  exist  in  the  fibrin  teaches  the  same  thing. 

Probably,  the  principal  cause,  at  least  that  which  first  leads  to 
the  stagnation,  is  the  loss  of  tone  or  power  to  contract  in  the  ves- 
sels. It  has  been  demonstrated  that  even  the  smaller  arteries  and 
veins  possess  not  only  contractile  tissue,  but  also  muscular  fibre. 
The  capillaries,  as  well,  have  contractile  tissue ;  indeed,  although 
no  muscular  fibre  has  been  detected  in  the  coats  of  capillary  tubes, 
it  is  not  going  far  to  doubt  they,  being  a  continuation  of  the  larger 
vessels,  would  partake,  although  in  a  limited  degree,  of  their  cha- 
racter. May  it  not  be  that  the  bloodvessels  perform  an  action 
analogous  to  that  performed  by  the  intestinal  canal.  It  is  difficult 
to  conceive  the  object  for  which  muscles  exist  in  the  coats  of  vessels 
if  it  be  not  to  assist  in  passing  the  blood  along  the  canal.  The 
heart  has  long  had  imposed  upon  it  the  responsibility  of  forcing 
the  blood  to  every  part  of  the  body ;  but  it  will  not  diminish  the 
importance  of  that  organ  to  admit  that  it  may  be  assisted  by  the 
vessels  themselves.  With  regard  to  the  capillaries,  there  is  cer- 
tainly reasonable  doubt  as  to  their  power  to  assist  {vide  Virchow, 
already  quoted) ;  if,  however,  it  be  true  that  some  vital  action  re- 
siding in  the  extra-capillary  cells  causes  the  fluid  to  permeate  these 
minute  tubes,  then  it  may  at  once  be  inferred  that  this  cellular 
power  is  disturbed  or  destroyed  in  consequence  of  the  morbid  ac- 
tion going  on,  and  hence  the  stagnation. 

We  have  now  reached  a  point  in  the  "inflammatory  process"  at 
which  a  change  of  function  is  apparent.  All  the  conditions  neces- 
sary to  healthy  nutrition  are  absent,  the  blood  is  stagnant,  the 
nervous  influence  is  deranged,  assimilation  impossible,  the  period 
of  incubation  has  passed, — the  disease  is  established. 


m 


u 


PRINCIPLES    OF    SURGERY. 


t 


I 


ff! 


!     , 


CHAPTEE    III. 

More  Extensive  View— Number  of  Products,  viz.,  Scrum,  Liquor  Sanguinis, 
Fibrin,  or  Inflammatory  Lymph,  &c.— Causes  of  Inflammation— Various 
Divisions. 

Thus  far,  in  studying  the  inflammatory  process,  our  attention 
has  been  necessarily  confined  to  a  single  vessel.  Now,  let  us  take 
a  more  extensive  and  comprehensive  view  of  the  inflamed  part. 
Not  only  one  but  several,  perhaps  many,  capillary  vessels  will  be 
simultaneously  involved ;  be  aff'ected  in  all  respects  the  same ;  and 
finally  in  all,  about  the  same  time,  the  blood  will  cease  to  move. 
Extending  the  view,  it  will  be  seen  that  in  the  immediate  neigh- 
borhood of  these  paralyzed  vessels  are  others,  undergoing  those 
primary  changes  which  have  been  described,  and  which  are  duly 
affected  in  the  same  manner  as  were  those  primarily  aff'ected.  Con- 
tinuing our  observation  to  tissue  farther  removed  from  the  central 
point  of  disease,  there  will  even  yet  be  observed  active  congestion 
or  limited  excitement,  and  apparent  efforts  being  made  to  make 
accommodation  for  the  in-rushing  blood. 

In  speaking  of  the  dilatation,  over-distension,  and  final  para- 
lysis, I  did  not  state  the  important  fact  that  the  vessels  are  not 
alone  increased  in  calibre,  but  are,  as  well,  elongated.  The  small 
vessels,  indeed,  present  a  varicose  or  tortuous  appearance.  More- 
over, they  are  not  uniformly  dilated,  but  here  and  there  they  pre- 
sent a  sacculated  appearance,  as  seen  in  the  annexed  diagram. 
Now,  must  not  this  be  considered  an  already  anxious  preparation 
of  nature  to  form  new  bloodvessels  in  connection  with  the  plastic 
material  which  has  been  copiously  eff'used  for  the  purpose  of  com- 
pleting repair,  should  the  inflammatory  action  fortunately  be  ar- 
rested ?  These  points  of  sacculation  may  very  easily  be  converted 
into  offshoots,  and,  as  will  be  seen  hereafter,  thus  made  to  afford 
channels  by  which  blood  may  be  supplied  to  complete  the  healing 
process. 

There  are  certain  products  of  inflammation  which  will  have  to 
receive  attention  as  we  continue  to  trace  the  inflammatory  process. 


CAUSES    OF    INFLAMMATION. 


35 


At  present  I  will  only  enumerate  them.  They  are,  1st.  Serum ; 
2d.  Liquor  sanguinis ;  3d.  Inflammatory  lymph,  or  altered  fibrin ; 
4th.   Blood;   and,  5th.   Altered  mucus.     These    are    immediate 


Small  TeaieU  of  an  inflamed  pericardium.  (Paget.) 

products  of  the  disease,  but  there  are  others  which  are  more  re- 
mote, yet  of  no  less  importance.  These  latter  products  result  from 
changes  which  may  take  place  in  the  lymph,  and  from  the  effects 
of  that  product  upon  the  tissue  involved.  Speaking  generally,  the 
lymph  may  become  organized,  as  will  be  hereafter  explained,  or  ifc 
may  degenerate  into  pus.  Before  proceeding  to  fully  consider 
these  products  of  the  disease,  I  purpose  to  consider  the  various 

Causes  of  Ivflammation. — They  are  numerous  and  varied,  but 
may,  by  classification,  be  made  easy  to  remember. 

A  common  and  convenient  division  is  into  predisposing  and  ex- 
citing ;  or,  it  may  be,  into  local  and  general,  or  external  and  in- 
ternal, or  specific  and  non-specific.  The  predisposing  causes  may 
be  subdivided  into  local  and  general.  A  local  predisposing  cause 
may  have  been  inherited,  or  it  may  have  been  acquired  after  birth. 
It  is  a  fact  frequently  observed  that  a  certain  tissue  or  organ  is 
preternaturally  weak,  a  condition  which  has  existed  all  the  life- 
time, or  since  a  certain  period  of  life.  A  tissue  thus  weak  is 
more  liable  to  be  attacked  with  disease  than  those  which  are  in 
health.  Individual  tissues  or  organs,  like  individual  persons,  are, 
in  consequence  of  imperfect  development,  more  subject  to  the 
casualties  of  life.     It  requires  no  proof  to  make  it  plain  that  cer- 


86 


PRINCIPLES    OF    SURGERY. 


'\    !: 


Hi 


tain  parts  of  the  foetus  may  be  imperfectly  developed  in  conse- 
quence of  faulty  conception  or  faulty  uterine  nourishment.  The 
vice  or  imperfection  of  either  parent  may  be  represented  in  the 
child ;  or  certain  other  influences  may  aflfect  the  integrity  of  the 
ovum  or  the  more  mature  foetus,  so  as  to  mar  the  process  of  devel- 
opment. Mal-nutrition,  either  during  foetal  life  or  after  birth,  or 
an  attack  of  some  disease,  may  beget  a  condition  permanently  weak 
in  a  part,  whereby  that  patt  is  susceptible  to  any  exciting  cause 
of  inflammation. 

It  has  already  been  shown  that  certain  conditions  are  necessary 
to  secure  healthy  nutrition — natural  repair ;  and  that  if  but  one 
of  these  conditions  be  absent,  there  will  follow,  sooner  or  later,  a 
morbid  condition  in  the  part  affected ;  and  when  the  body  is  ex- 
posed to  an  exciting  cause  of  inflammation  that  morbid  tissue  is 
likely  first  to  feel  the  effects.     But  the  whole  system  may  be  pre- 
disposed to  inflammation.     Primarily  the  whole  structure  of  the 
body  may  have  been  defective;  or,  secondarily,  the  blood  may 
have  become  vitiated.    This  general  defect  may  have  been  induced, 
or  it  may  be  a  heritage.     When  acquired  there  are  many  causes 
which  may  have  been  in  action.     The  blood  may  be  impure.     It 
may  always  have  been  so,  or  it  may  have  become  so,  as  the  result 
of  imperfect  performance  of  duty  on  the  part  of  certain  organs, 
or  from  the  reception  of  crude  or  deficient  aliment,  derived  from 
vicious  food,  or  from  taking  too  much,  or  perhaps  too  little  food, 
or  it  may  be  from  a  failure  in  digestion.     Again,  the  blood  may 
not  be  duly  developed.     The  conditions  necessary  for  this  may  be 
wanting.     Impurity  of  the  blood,  so  injurious  to  health  and  the 
well-being  of  tissues,  will  ensue,  if  that  fluid  be  not  continually 
aerated,  or  if  morbid  material  should  enter  by  the  lungs.     If  one 
or  more  of  the  excretory  organs  fail  to  discharge  its  function 
aright  and  the  effete  matter — those  elements  which  have  formed  a 
part  of  the  fabric,  but  which  now  have  perished,  and  are  floating 
in  the  fluids  of  the  body — be  not  duly  removed  from  the  system  by 
the  kidneys,  or  the  skin,  or  the  bowels,  then  it  may  be  the  blood 
will  be  poisoned,  and  individual  tissues  in  consequence  become 
sufferers,  and  therefore  predisposed  to  inflammatory  disease. 

Still,  again,  the  blood,  in  consequence  of  a  certain  condition  in 
which  it  happens  to  be  found,  or  in  consequence  of  being  possessed 
of  certain  elements,  may  receive  from  without  poisonous  elements, 


CAUSES    OF    INFLAMMATION. 


87 


specific  elements,  which  possess  the  power  to  beget  specific  inflam- 
matory disease,  such  as  small-pox,  measles,  scarlet  fever,  &c.  Still 
further  may  be  mentioned  the  taking  of  too  much  food,  even  though 
that  food  may  be  digested.  When  a  state  of  plethora  is  induced 
by  overmuch  eating,  the  blood  can  scarcely  be  in  a  healthy  con- 
dition, but  rather  becomes  gross  and  ill-fitted  for  nutrition,  and 
a  predisposing  cause  of  inflammation,  ready  to  act,  should  any  part 
be  subjected  to  pathological  irritation.  Lastly,  changes  of  weather, 
by  which  the  body  is  exposed  to  great  and  sudden  variations  in 
temperature,  whereby  nutrition  and  development  are  impaired, 
will,  if  long  continued,  render  the  whole  system  liable  to  inflam- 
matory disease. 

Exciting  or  Local  Causes  of  Inflammation. — The  first  are  those 
which  actually  injure  organized  structure,  as  mechanical  injuries 
and  chemical  agents,  which  tend  to  immediate  destruction  of  tis- 
sue; also  heat,  extreme  cold,  and  friction.  2dly.  Those  which 
act  through  the  sentient  extremities  of  the  nerves,  as  concussion, 
pressure,  irritating  applications,  as  mustard,  cantharides,  &c. 
3dly.  Anything  which  produces  a  peculiar  impression  and  gives 
rise  to  a  specific  action  of  an  inflammatory  nature,  such  as  decom- 
posed animal  matter,  pus  arising  from  specific  diseases,  dissecting 
wounds,  &c.  A  fourth  class  of  causes  is  given ;  that  is,  such  cir- 
cumstances as  produce  a  sudden  change  in  the  feeling  of  a  part  as 
that  experienced  in  the  viscera  of  the  abdomen  after  the  removal 
of  fluid  in  ascites.  Under  this  class  may  be  included  any  change 
in  local  nerves,  whereby  deviations  from  normal  nutrition  may 
take  place.  (Simon.) 

The  terms  specific  and  non-specific,  as  applied  to  causes  of  in- 
flammation, scarcely  require  to  be  explained.  They  are  almost 
synonymous  with  unhealthy  and  healthy,  a  division  already  indi- 
cated, yet  an  inflammation  maybe  unhealthy  without  being  specific. 
A  specific  cause  of  inflammation  is  one  which  gives  rise  to  a  defi- 
nite kind  of  inflammation,  as  in  the  poison  of  small-pox  and  of 
syphilis,  &c.  A  non-specific  cause  is  one  which  has  a  more  general 
source. 


88 


riMi! 


PRINCIPLES    OP    SURGERY. 


CHAPTER    IV. 

Symptoms  of  Inflammation— Causes  of  each — Value  in  Diagnosis. 

And  now,  bearing  in  mind  the  varied  causes  of  inflammation, 
and  fixing  the  attention  upon  the  pathological  condition  of  an 
inflamed  part;  not  alone  upon  a  single  vessel,  whose  coats  are 
paralyzed,  and  from  which  exudation  of  liquor  sanguinis  is  copi- 
ously taking  place,  but  upon  a  wider  district,  in  which  are  to  be 
found  many  vessels  in  the  various  stages  of  the  inflammatory  pro- 
cess ;  some  with  blood  stagnant,  some  in  which  it  moves  sluggishly, 
some  through  which  it  rushes  with  increased  speed, — taking  this 
more  comprehensive  view  of  an  inflamed  part,  it  will  be  a  more 
easy  task  to  consider  the  various  symptoms  which  characterize  the 
inflammatory  process,  so  far  as  we  have  traced  it,  and  to  examine 
the  symptoms  which  may  be  looked  upon  as  diagnostic  marks  of 
the  disease. 

The  symptoms  of  inflammation  may  be  divided  into  local  and 
general.  The  local  are  pain,  heat,  redness,  swelling,  to  which  is 
commonly  added  throbbing.  Pain  is  a  very  early  and  constant 
symptom  as  a  general  thing,  and  such  would  naturally  be  ex- 
pected. It  is  the  office  of  the  peripheral  extremities  of  the  nerves 
to  guard  the  structures  wherein  they  are  distributed,  and  to  give 
warning  to  the  central  system  on  the  approach  of  danger.  The 
invitation  by  which  the  inflammatory  process  is  initiated,  acting 
upon  and  through  the  nerves,  will  from  the  first  produce  uneasi- 
ness in  the  nerve-tissue  itself,  and  prompt  and  constant  pain  is  the 
common  result  of  the  inflammatory  process.  The  pain  of  inflam- 
mation may  be  said  to  arise  from  two  causes,  one  of  which  is  dis- 
turbance of  or  injury  to  the  nerve-substance ;  the  other  is  derived 
from  indirect  effects  upon  the  nerves,  due  to  the  morbid  condition 
of  the  tissue, — changes,  perhaps,  in  the  cellular  elements,  and  the 
free  transudation  which  follows  the  paralysis  of  the  vessels.  The 
in-rushing  blood  may  be  supposed  to  increase  the  pathological  irri- 
tation which  has  arisen  by  pressing  upon  the  irritated  nerves  while 


SYMPTOMS    OF    INFLAMMATION. 


39 


in  a  disturbed  state ;  also  the  several  products  of  inflammation,  the 
exuded  serum,  the  liquor  sanguinis,  and  subsequently  the  pus 
when  it  has  formed,  will,  no  doubt,  in  like  manner  by  pressure 
maintain  and  increase  the  pain.  But  the  pain  of  inflammation  is 
not  always  alike  with  the  same  cause  and  amount  of  inflammation. 
The  intensity  of  pain  depends  upon  the  nature  of  the  tissue  in- 
volved. If  it  be  abundantly  supplied  with  nerves,  the  pain  will 
necessarily  be  greater.  Again,  if  the  tissue  be  dense  and  unyield- 
ing, the  pain  will  be  correspondingly  great.  For  instance,  in  in- 
flammation of  the  periosteum,  a  dense,  unyielding,  fibrous  mem- 
brane, the  pain  is  very  great ;  and  the  same  is  witnessed  in  the 
bone  itself  when  inflamed,  also  in  the  torturing  toothache.  In  such 
tissues  where  the  nerves  are  irritated,  attended  by  congestion  or 
efi"usion,  the  pain  becomes  exquisite ;  for,  with  the  pressure,  there 
is  an  equal  counter-pressure.  On  the  contrary,  when  the  so-called 
cellular  tissue  is  the  seat  of  inflammation,  the  pain  by  no  means 
corresponds  with  the  actual  amount  of  inflammation.  This  difier- 
ence  between  certain  tissues  of  the  body  with  regard  to  suscepti- 
bility and  inability  to  accommodate  themselves  to  abnormal  condi- 
tions, bears  an  analogy  to  that  well-known  diff'erence  which  exists 
between  individual  beings.  All  persons  are  not  equally  aff"ected 
in  the  same  degree  of  inflammation,  or  in  any  other  disease. 
Some  individuals  are  more  sensitive  than  others ;  and  some  tissues 
are  likewise  more  sensitive  than  others,  although  in  other  respects 
there  may  be  equality. 

To  what  extent  may  pain  be  considered  a  diagnostic  mark  of  in- 
flammation ?  It  must  be  mentioned  that  pain  may  be  absent  in 
consequence  of  paralysis ;  it  therefore  cannot  be  recognized  as  an 
infallible  diagnostic  mark  ;  but  when  pain  is  absent  in  consequence 
of  paralysis,  the  most  superficial  observer  will  be  able  to  discern 
it.  On  the  other  hand,  pain  attends  other  diseases  as  well  as  in- 
flammation. The  pain  of  neuralgia  is  very  severe,  but  it  may  be 
distinguished  from  the  pain  of  inflammation  by  the  manner  in 
which  it  commences.  Unlike  the  pain  of  inflammation,  it  is  sudden 
in  its  onset,  and  is  quite  as  severe  at  first  as  at  any  subsequent 
period,  while  at  the  same  time  there  will  be  an  absence  of  the  other 
ordinary  symptoms  of  inflammation.  Again,  the  pain  of  colic  may 
be  mistaken  for  that  of  inflammation  ;  indeed,  it  is  very  commonly 
done  by  the  non-nrofessional  -,  but  this,  alsoj  is  sudden  in  its  an- 


40 


PRINCIPLES    OP    8DR0ERY. 


pearance,  and  .s  often  as  great  at  first  as  at  any  subsequent  time. 
Moreover,  the  pam  of  colic  is  relieved  by  pressure,  while  the  pain 
of  mflammafon  ,s  always  increased  thereby.    And,  it  is  important 

1/n ^^'''  ir^  '^'  ''"'''  °^  inflammation  in  an  internal 
organ  the  pam  suddenly  cease  and  does  not  recur,  it  is  always  to 
be  regarded  with  concern,  inasmuch  as  it  indicates  that  the  tissue 

and  that  the  relief  which  the  patient  so  much  enjoys  is  but  a  fore 
taste  of  that  ease  from  bodily  pain  which  death  brings 

ffeat  la  a  very  constant  symptom  of  infiammation.    A  difference 
of  opinion  prevails  as  to  the  cause  of  this  symptom.     Physiolo- 
gists  do  not  quite  agree  as  to  the  source  of  animal  heat  in  the 
human  body ;  as  to  the  nature  of  that  process  by  which  a  certain 
amount  of  heat  is  constantly  created  in  the  body.     All,  however 
are  agreed  that  in  the  process  of  nutrition  there  is  a  certain  amount 
of  heat  regularly  developed  in  every  part  of  the  body.    Wherever 
he  blood  flows,  there  heat  is  evolved.     It  may  be  by  waste  of 
tissue,  or  It  may  be  by  some  strictly  chemical  change  in  connec- 
tion with  the  transudation  which  takes  place  through  the  capillary 
coats;  but  it  matters  not  for  our  purpose  as  students  of  the  science 
ot  surgery.    It  ,s  sufficient  to  know  that  the  process  by  which  heat 
IS  produced  in  the  body  in  health,  or  some  like  process'  i^  found 
be  actively  at  work  where  inflammation  has  been  kindled,  and  con- 
sequently in  that  part  a  superabundance  of  heat  is  always  found 

Lr/K  ;  i'?"  ''  ^''^  ''"'"^■"S  satisfaction,  demonstrated  the 
fac  that  the  emperature  of  a  part  inflamed  is  greater  than  that 
of  the  arterial  blood  going  to  the  part,  and  that  the  heat  of  the 
blood  going  from  the  part  is  less  than  the  temperature  of  the  blood 
m  the  part,  while  at  the  same  time  it  is  greater  than  the  blood  in 
a  corresponding  artery. 

Heat  in  most  cases,  is  a  trustworthy  diagnostic  s„tom  of  in- 
flammation, but  It  IS  not  altogether  so.  The  heat  may  seem  to  be 
great  to  the  patient  in  consequence  of  a  morbid  state  of  the  nerves- 
and  again,  a  structure  inflamed,  when  freely  supplied  with  nerves' 
may  seem  to  have  a  higher  temperature  than  it  really  has,  as  wli 

ol2 V/  "'"t  "P"'"^"'-     ''  ''  ^^-'^  «--«-/  to  point 
out  the  difference  between  the  heat  of  inflammation  and  fhat  which 

characterizes  the  burning  cheek  of  shame,  and  also  that  of  hectic. 

They  can  always  be  distinguished  from  the  absence  of  all  the  symp- 


SYMPTOMS    OF    INFLAMMATION. 


41 


quent  time, 
ile  the  pain 
3  important 
an  internal 
s  always  to 
t  the  tissue 
ommenced, 
but  a  fore- 

.  difference 
Physiolo- 
eat  in  the 
1  a  certain 
,  however, 
lin  amount 
Wherever 
'  waste  of 
n  connec- 
!  capillary 
he  science 
?hich  heat 
J  found  to 
,  and  con- 
lys  found 
;rated  the 
than  that 
at  of  the 
the  blood 
blood  in 

>m  of  in- 
em  to  be 
3  nerves ; 
1  nerves, 
3,  as  will 
to  point 
at  which 
f  hectic, 
le  symp- 


toms and  circumstances  of  inflammation  in  the  one  case,  and  the 
presence  of  graver  constitutional  symptoms  in  the  other. 

Redne89.—ln  inflammation  the  flow  of  blood  is  increased  to  the 
affected  part,  and  as  the  capillary  coats  gradually  yield  under  the 
constantly  increasing  pressure,  greater  space  is  allowed  for  the 
presence  of  red  corpuscles.    Small  vessels,  through  which  the  cor- 
puscles could  but  pass  in  single  file,  have  crowding  through  them 
much  larger  numbers.     Bloodves- 
sels are  not  suddenly  formed  in  an 
inflamed  part,  as  was  at  one  time 
.  supposed.     The  redness  is  due  to 
this  crowding  of  the  distended  ves- 
sels by  red  corpuscles.    The  liquor 
sanguinis  exudes,  leaving  the  cor- 
puscles mainly  to  occupy  the  capil- 
lary tube.     Often  the  little  cells 
will  break  down,  or  part  with  the 
coloring  matter,  which  will  tinge 
the  transuding  liquor  sanguinis. 

Redness,  although  a  constant 
symptom  of  acute  inflammation, 
may  not  be  recognized  as  a  certain 
sign  of  the  disease,  for  redness 
sometimes  results  from  other  mor- 
bid conditions.  There  are  certain 
conditions   of   the    blood,   as    in    r-  , 

K,  vuvi,     aa      in       Enlargement  of  vesBels,  shown  in  Hunter'a 
scurvy,    where    the    red   corpuscles  •?"«'"'«'>  of  t»>«  ears  of  a  rabbit,  one  of  which 

easily  part  with  their  co\ovmgZ^T(Zt^'''"^'''^ ''"'""" '''"^'^'' 
matter,     which,    being     admixed 

with  the  serum,  may  collect  in  a  part,  and  give  rise  to  a  very  high 
degree  of  redness.  The  intensity  of  the  redness,  whatever  may  be 
the  cause,  will,  of  course,  vary  much,  according  as  the  blood  is 
arterial  or  venous.  In  the  former  case  it  will  be  of  a  brighter  hue  ; 
in  the  latter  it  will  be  darker,  perhaps  even  dusky. 

Swelling.— When  a  part  becomes  inflamed  there  is  a  tendency 
therein  to  swell ;  the  relative  size  of  that  part  is  increased.  The 
supposition  would  naturally  arise  that  an  increase  of  blood  would 
increase  the  volume  to  a  corresponding  extent,  and  generally,  no 
doubt,  such  is  the  case=     Yet  the  vessels  may  be  dilated  so  as  to 


1 

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42 


PRINCIPLES    OP    SURGERY. 


contain  a  very  much  larger  quantity  of  blood  than  is  natural,  and 
at  the  same  time  the  structure  in  which  these  vessels  are  located 
may  be  lessened  in  dimensions  (perhaps  by  the  pressure  of  the  dilat- 
ing vessels),  so  that  the  natural  volume  of  the  whole  is  retained. 
In  the  first  step  of  the  inflammatory  process  such  is  the  case,  but 
when  the  coats  become  paralyzed,  then  the  liquor  sanguinis  occu- 
pies the  intercapillary  substance.     Indeed,  the  cells  of  which  the 
tissue  is  composed  are  soon  engaged  in  a  morbid  action,— unnatural 
development.     They  individually  swell  by  imbibition  of  the  fluid 
which  has  transuded.  (Virchow.)   In  those  tissues  which  are  yield- 
ing the  swelling  will  be  greater  than  in  those  which  are  not.   And 
here  I  wish  to  point  out  the  important  fact  that  swelling  is  salu- 
tary in  its  efi'ects ;  it  may,  indeed,  be  looked  upon  as  a  curative 
effort.     In  a  given  amount  of  inflammation  in  a  certain  tissue,  the 
degree  of  pain  to  some  extent  depends  upon  the  amount  of  swell- 
ing which  attends ;  that  is,  whether  the  tissue  is  yielding  or  other- 
wise, for  we  have  already  learned  tliat  inflammation  of  dense  tissue 
is  more  painful,  because   the  irritated   nerves  are  more  pressed 
upon.     Consequently,  when  swelling  takes  place,  one  of  the  most 
active  agents  in  feeding  the  inflammation  is  removed  or  modified. 
Swelling  then  relieves  the  irritated  nerves,  and  tends  to  arrest  in- 
flammatory action.     The  degree  of  swelling,  we  have  seen,  will 
depend  upon  the  nature  of  the  tissue  or  organ  involved. 

As  a  diagnostic  gymptom,  swelling  is  not  very  trustworthy.  It 
has  been  shown  that  considerable  inflammation  may  exist  without 
a  corresponding  amount  of  swelling.  Moreover,  swelling  often 
takes  place  independently  of  inflammatory  action,  as  in  passive 
congestion,  where  there  is  a  mechanical  obstruction  to  the  return 
of  venous  blood,  or  when  something  interferes  with  the  circulation 
of  blood  in  a  part. 

These  four  symptoms,  pain,  heat,  redness,  and  swelling,  when 
taken  singly,  cannot  be  said  always  to  indicate  inflammatory  ac- 
tion,—are  not  diagnostic  marks ;  but  when  two  are  found  coexist- 
ing,  the  one  increases  the  importance  of  the  other ;  and  when  the 
whole  four  are  seen  in  connection,  they  may  be  regarded  as  very 
reliable  symptoms  of  inflammation. 

Another  symptom,  which  is  mostly  always  given  with  the  fore- 
going, is  throbbing.     It  may  be  said  to  indicate  a  certain  stage  of 

the  disease,  to  which  wo  havn  nnf  ab   vnf   trono/1  ♦».<»   'Vfl^. .*---. 


I 


SYMPTOMS    OF    INFLAMMATION. 


48 


iiiuiaLui 


process,  namely,  commencing  suppuration.  This  sensation  of  throb- 
bing is  due  to  the  wave  of  blood  which,  coming  from  the  heart, 
endeavors  to  force  its  way  into  and  through  the  inflamed  part,  and 
which,  being  obstructed,  causes  the  arteries  and  heart  to  labor  in 
their  eff"orts  to  overcome  the  obstruction.  Every  wave  of  blood 
increases  the  pressure  already  felt  by  the  sensitive  nerves ;  and 
the  pain,  constantly  experienced,  is  at  each  pulsation  intensified 
for  a  moment,  and  hence  the  throbbing. 

Other  local  symptoms  E,re  sometimes  given  in  connection  with 
the  above,  as  derangement  of  function.  It  is,  however,  unneces- 
sary to  say  more  here  than  that  the  absence  of  the  natural  condi- 
tions necessary  for  nutrition  infers  derangement  of  function. 

Constitutional  Symptoms  of  Inflammation.— The  system  gene- 
rally does  not  remain  impassive  or  unaffected  when  a  part  of  the 
body  is  inflamed.  There  is  a  most  intimate  connection  between 
one  part  of  the  body  and  every  other  part,  so  that  one  part  or 
organ  cannot  long  go  in  pain  or  be  disturbed  without  the  whole 
taking  cognizance  of  the  local  distress,  and  to  a  great  extent 
becoming  aff-ected  thereby.  The  quickness  with,  and  extent  to 
which  this  is  accomplished,  will  depend  upon  the  degree  or  inten- 
sity of  the  local  afl'ection,  and  the  susceptibility  which  may  attach 
to  the  constitution. 

The  general  symptoms  may  all  be  included  u?ider  the  general 
term  "  inflammatory  fever."  Fever  is  always  present  when  inflam- 
mation is  at  all  worthy  the  notice  of  the  surgeon.  It  is  generally 
preceded  by  a  well-marked  chill,  which  is  of  short  duration  and 
varying  intensity.  The  fever  is  characterized  by  a  dry  and  heated 
Bkin,  and  an  arrest  of  all  the  secretions.  IIow  is  this  fever  pro- 
duced ?  In  the  first  place,  the  irritation  and  pain  which  give  rise 
to,  and  also  result  from  the  inflammation,  and  which  cause  irre- 
gular action  in  the  vascular  structure  of  the  part,  gradually  pro- 
duce a  similar  eff"oct  upon  the  whole  vascular  systoin,  including 
the  heart  itself.  The  morbid  action  of  the  vessels  in  the  aff-ected 
part,  characterized  at  first  by  increased  tone,  seems  to  extend  by 
continuity  along  the  network  of  capillnriea  and  the  smaller  arte- 
ries, and  then  on  to  the  heart  itself.  The  pronipt  manner  in  which 
the  heart  sometimes  becomes  aff-ected  and  increased  in  action  would 
lead  to  the  belief  that  it  was  through  the  nerves'  reflex  action  that 
tne  conatituiioiiui  irritation  was  created. 


T^ 


r  'I 


44 


PRINCIPLES    OP    SURGERY. 


;/ 


m     ^.'ii 


i 


In  the  second  place,  the  blood  becomes  gradually  contaminated 
by  the  products  of  the  local  disease.     In  consequence  of  those 
changes  which  we  have  seen  take  place  in  an  inflamed  part,  a  poison 
is  engendered.     This  poison,  by  collateral  circulation,  soon  finds 
its  way  into  the  general  circulation.     In  this  way  certain  changes 
are  effected  in  the  whole  volume  of  blood,  which  will  be  fully  ex- 
plained hereafter.     What  is  important  here  is  the  fact  that  the 
blood,  thus  poisoned,  acting  in  conjunction  with  the  nervous  irri- 
tation already  referred  to,  gives  to  the  whole  vascular  system, 
including  the  lymphatics,  an  unnatural  degree  of  tone,  and  this 
is  the  commencement  of  inflammatory  fever.     The  explanation  of 
this  can  be  easily  understood.     The  vessels  contract,  and  thereby 
their  calibre  is  diminished.     The  coats  are  brought  into  such  a 
state  that  transudation  of  fluid  cannot  take  place,  at  least  as  in 
health.    The  pores,  so  to  speak,  are  closed.    At  the  same  time  the 
heart  labors,  and  the  blood  hurriedly  streams  along  to  and  from 
every  part  of  the  body  incapable  of  supplying  nutriment  to  or 
carrying  eff"ete  matter  from  any  structure.     If,  under  such  circum- 
stances, the  skin  be  examined,  it  will  be  found  there  is  an  absence 
of  the  usual  moisture,— there  is  no  perspiration.     The  skin  is  dry 
while  the  blood  is  welling  forth  from  the  heart  with  determined 
force  into  the  integument,  in  common  with  every  other  part  of  the 
body.     The  amount  of  heat  generated  in  the  body  at  such  times 
is  probably  greater  than  in  healthy  action,  while  at  the  same  time 
the  absence  of  evaporation  from  the  surface  of  the  body  tends 
very  much  to  increase  the  temperature.     Here,  then,  is  an  expla- 
nation, easy  and  simple,  of  two  common  symptoms  of  inflammation, 
namely,  excessive  heat  and  dryness  of  skin. 

This  increase  of  tone,  or  closeness,  I  may  say,  in  the  texture 
of  vessels,  by  which  transudation  \h  arrested,  is  exhibited  as  well 
in  the  lymphatic  and  glandular  structures,  so  as  to  affect  the  various 
sources  of  excretion.  Secretion  cannot  go  on  as  in  health  ;  hence 
the  fact  that  in  inflammation  the  urine  becomes  scanty.  But  little 
fluid  can  transude,  and  that  is  loaded  with  the  eff'ete  matter  of  the 
body  so  as  to  make  it  highly  colored.  The  bowels,  also,  are  con- 
stipated, because  the  various  glands  connected  therewith  iiro  inca- 
pable of  action,  the  vessels  therein  being  contracted,  and  there  is 
but  little  secretion  upon  the  mucous  surface.  The  tongue,  in  com- 
mon with  other  parts  of  tho  prisna  yitn.  nartici»ateH  in  thfl  "^^neral 


! 


PROGNOSIS    OF    INFLAMMATION. 


45 


i 


itarainated 
e  of  those 
•t,  a  poison 
soon  finds 
in  changes 
e  fully  ex- 
t  that  the 
rvous  irri- 
ir  system, 
!,  and  this 
anation  of 
id  thereby 
ito  such  a 
east  as  in 
e  time  the 
and  from 
lent  to  or 
;h  circum- 
in  absence 
kin  is  dry 
etermined 
•art  of  the 
juch  times 
same  time 
ody  tends 
an  expla- 
immation, 

e  texture 
od  as  well 
lie  various 
th ;  hence 
But  little 
ter  of  the 
are  con- 
iiro  inca- 
1  there  is 
e,  in  com- 
i-  general 


disturbance,  and,  as  it  comes  under  convenient  notice,  its  appear- 
ance is  anxiously  studied  by  the  surgeon.  The  papillae  of  the 
tongue  stand  out  prominently  and  with  unusual  redness,  and  the 
surface  generally  k  covered  with  a  whitish  or  brownish  coat,  due 
to  the  partially  arrested  and  changed  condition  of  the  mucus,  while 
the  borders  of  the  organ  are  reddened. 

The  head  is  also  more  or  less  affected  in  inflammation,  there 
being  generally  headache,  with  some  obtuseness  or  disturbance  of 
the  mental  faculties.  This  may  be  the  effect  of  nervous  sympathy, 
at  least  in  part ;  for  there  is  at  all  times  a  close  sympathy  between 
the  head  and  the  bowels.  But  the  cerebral  disorder  is  also  in  part 
due  to  the  state  of  the  bloodvessels  within  the  head,  which  will 
participate  in  the  common  vascular  excitement.  These  various 
constitutional  symptoms  are  not  likely  to  be  mistaken,  and  when 
preceded  by  and  accompanied  wih  the  local  symptoms,  the  diag- 
110818  of  the  disease  is  most  certain. 


CHAPTER    V. 

Prognosis  of  Inflammation— Course  and  Termination,  viz. :  1.  Resolution.    2 
Delitoscence.     3.  Extension,   first,  by  Continuity;  socond,  by  Contiguity- 
tbird,  by  tlie  Circulation-Each  cxplained-Fibrin  in  the  System  and  out 
of  it-"  Cupped  and  Buffed;"  fourth,  by  absorption  ;  «fih,  by  the  agcnev  of 
the  nerves. 

The  decision  of  the  surgeon  with  regard  to  prognosis  will  depend 
upon  a  variety  of  circumstances,  such  as  the  age  of  the  patient, 
the  constitution,  the  cause  of  the  disease,  the  stage,  and  the  general 
surroundings  of  the  patient,— the  care  and  attention  he  will  proba- 
bly receive,  and  the  faithfulness  with  which  the  surgeon's  instruc- 
tions will  be  carried  out. 

As  a  general  thing  inflammation  runs  high  in  the  young,  and 
also  up  to  middle  life ;  at  the  same  time  its  course  is  sooner  run 
to  one  or  other  termination.  In  the  young  the  powers  of  life  are 
active,  and  quick  to  resist  anything  which  causes  pain,  and  speedy 
in  their  efforts  to  get  rid  of  the  irritation  and  to  effect  restoration, 
,.  ..-^waij  JwiH^,^  iii  iiic  juuiig  uizij  icad  50  senous  results. 


i 


,.;:-i 


46 


PRINCIPLES    OF    SURGERY. 


Hi 


'.    ■    ,H 


I'  i 


On  the  contrary,  in  the  aged  there  is  a  comparative  slowness  to 
redress  an  evil  condition,  to  attempt  to  get  rid  of  a  cause  of  irrita- 
tion, and  to  regain  the  normal  state. 

The  constitution  of  the  patient  will  be  fully  considered.  When 
it  is  quite  sound  we  have  circumstances  analogous  to  those  just 
mentioned  as  characterizing  inflammation  in  the  young ;  and  Avhen 
it  is  unsound  they  are  analogous  to  the  condition  of  the  aged  in 
this  disease. 

The  cause  or  causes  of  the  inflammatory  action  must  be  remem- 
bered in  order  to  form  a  correct  prognosis  ;  the  predisposing  cause 
and  the  local  cause,  whether  each  can  be  readily  removed  or  not 
and  whether  it  is  potent  or  otherwise.  The  stage  of  the  disease 
also  will  govern  the  prognosis ;  that  is,  the  extent  to  which  morbid 
changes  have  taken  place  in  the  part,  and  the  eff'ects  thereof  on 
the  constitution.  And  lastly,  the  course  and  termination  of  the 
disease  will  often  and  very  much  depend  upon  the  position  of  the 
patient,  and  the  fidelity  with  which  the  various  directions  of  the 
surgeon  are  adhered  to.  Too  often  an  over  wise  nurse,  or  an 
attendant  led  by  inconsiderate  kindness,  acts  contrary  to  essential 
orders  in  regard  to  remedial  measures,  and  consequently  the  sur- 
geon's calculations  are  subverted. 

The  surgeon  will  be  expected  to  give  his  opinion,  first,  as  to 
whether  the  life  of  the  patient  is  in  danger;  and  secondly,  in  re- 
spect to  the  integrity  of  the  tissue  or  organ  affected  ;  whether  it 
is  likely  to  be  permanently  or  seriously  impaired ;  how  long  a  time 
must  elapse  before  a  cure  can  be  expected  by  the  unaided  powers 
of  nature,  or  by  the  assistance  of  the  surgeon ;  or  how  long  will 
it  probably  be  ere  the  irresistible  fatal  termination  will  arrive. 
These  are  the  questions  which  will  have  to  be  replied  to  in  render- 
ing a  complete  prognosis. 

The  Course  and  Terminations  of  Inflammation.— A.t  any  time 
during  the  inflammatory  process,  it  may  be  arrested  and  resolution 
supervene.  If  the  cause  be  removed  before  the  inflammatory 
action  has  too  far  advanced,  resolution  may  quickly  supersede  the 
morbid  action.  And  here  I  must  not  omit  to  point  out  the  inte- 
resting and  important  fact,  that  many  of  the  phenomena  of  in- 
flammation are  clearly  indications  of  nature,  intended  to  remove, 
if  possible,  the  cause  of  the  inflammation ;  as,  for  instance,  when 
a  grain  of  sand  is  lodged  in  the  oye,  the  immediate  effect  is  a 


COURSE    AND    TERMINATIONS    OF    INFLAMMATION.       47 


slowness  to 
use  of  irrita- 

sred.     When 

o  those  just 

5 ;  and  when 

the  aged  in 


it  be  remem- 
posing  cause 
oved  or  not, 
the  disease 
'hich  morbid 
i  thereof  on 
ation  of  the 
!ition  of  the 
tions  of  the 
urse,  or  an 
to  essential 
tly  the  sur- 

first,  as  to 
ndly,  in  re- 

whether  it 
long  a  time 
ided  powers 
)w  long  will 
will  arrive. 
3  in  render- 

t  any  time 
1  resolution 
flammatory 
persede  the 
lit  the  inte- 
Qcna  of  in- 
to remove, 
ancc,  when 
effect  is  a 


copious  secretion  by  the  gland,  and  thereby,  in  many  cases,  the 
offending  object  is  washed  away.     Other  instances  might  be  ad- 
duced to  show  the  same  kind  workings  of  nature;  but  I  shall 
hereafter  have  occasion  to  dwell  on  this  fact,  and  also  point  out 
certain  morbid  conditions  which  evidently  indicate  curative  efforts. 
The  terminations  of  inflammation  may  be  given  as  follows: 
First,  into  Resolution ;  secondly,  by  Delitescence,  or  by  what  is 
called  metastasis ;  that  is,  morbid  action  may  pass  away  entirely 
(delitescence),  or  it  may  disappear  from  one  place  and  appear  in  a 
second  place  (metastasis).     The  latter  is  often  seen  in  connection 
with  gonorrhoea,  a  specific  inflammation ;  the  disease  commences 
in  the  urethra,  and  after  a  time  it  suddenly  ceases  in  that  mem- 
brane, and   simultaneously  attacks   the  testicles.     Thirdly,  the 
inflammation  may  extend  to  other  structures.     This  may  take 
place,  1st,  by  continuity,  along  a  membrane  in  the  same  tissue,  as 
from  the  Schneiderian  membrane  to  the  mucous  membrane  of  the 
larynx,  and  to  the  bronchial  tubes ;  or  from  the  duodenum  to  the 
liver,  along  the  ductus  communis  choledochus.  2dly,  by  contiguity; 
that  is,  from  one  tissue  to  another  which  lie  in  contact ;  as  from 
the  mucous  membrane  of  vhe  intestine  to  the  muscular  coat,  and 
then  to  the  serous  portion ;  or  from  the  periosteum  to  the  bone, 
and  vice  versa.    3dly,  the  disease  may  extend  through  the  agency 
of  the  circulating  blood.     The  fact  has  been  before  stated,  that 
during  the  progress  of  inflammation  the  blood,  sooner  or  later, 
becomes  seriously  affected,  which  causes,  or  assists  to  produce 
inflammatory  fever.     The   blood  may   be  so  impregnated  with 
poison,  that,  as  it  courses  from  the  inflamed  part,  it  will  carry 
disease  to  other  and  remote  parts,  where,  perhaps,  in  consequence 
of  some  predisposition,  inflammation  is  also  established. 

It  now  becomes  necessary  to  consider  more  particularly  in  what 
these  changes  of  the  blood  consist— what  is  the  condition  of  the 
various  elements  of  the  blood  when  it  thus  possesses  the  unnatural 
power  to  produce  inflammatory  disease  in  a  part  remotely  situated 
from  the  tissues  originally  affected.  Looking  for  a  moment  at  the 
blood  when  in  a  state  of  health,  as  it  circulates  in  the  bo«ly,  it  may 
bo  divided  into  the  fluid  and  solid  constituents;  the  latter  floating 
in  the  former.  The  fluid,  or  liquor  sanguinis,  is  composed  of  the 
eerum  and  the  fibrin.  The  more  solid  elements  are  the  corpuscles, 
red  and  white,  and  some  granular  matter.     The  serum  of  th* 


48 


PRINCIPLES    OF    SURGERY. 


'  a 


liquor  sanguinis  is  composed  of  a  large  quantity  of  water,  albu- 
men, salts,  and  fatty  matter.    Now,  if  this  healthy  blood  be  taken 
from  the  system,  the  following  changes  will  be  observed  to  take 
place.     Under  ordinary  circumstances,  the  blood  soon  ceases  to 
be  altogether  fluid;  the  fibrin,  instead  of  remaining  in  a  soluble 
condition,  begins  at  once  to  solidify,  coagulate,  and  separates  itself 
from  the  serum ;  while  it  embraces  in  its  substance  the  corpuscular 
elements.     In  this  way  the  blood  is  divided  into  a  clot  and  the 
serum.     The  change  is  altogether  due  to  the  action  of  the  fibrin. 
But  when  inflammation  exists,  blood  taken  from  the  body  exhibits 
somewhat  different  characteristics,  the  first  and  most  striking  of 
which  is,  that  some  time  will  elapse  before  this  coagulation  of  the 
fibrin  commences  to  take  place,  and  when,  finally,  it  has  been 
effected,  the  clot  is  found  to  be  unusually  firm  and  tough.     Before 
attempting  to  account  for  these  phenomena,  it  will  not  be  out  of 
place  to  allude  to  the  important  question,  which  has  of  late  so 
much  engaged  the  attention  of  physiologists  and  pathologists; 
namely,  what  is  the  office  of  the  fibrin  in  the  human  system? 
Upon  this  subject  there  is  even  yet  some  difference  of  opinion. 
The  statement  of  Carpenter,  that  "  albumen,  fibrin,  and  organized 
tissue  are  somewhat  of  the  same  nature  as  that  which  exists  be- 
tween the  raw  cotton,  the  spun  yarn,  and  the  woven  fabric," 
cannot  be  received  at  the  present  day ;  indeed  he  has,  in  a  later 
edition,  very  materially  modified  his  teachings  in  this  respect.    He 
admits  that  fibrin  does  not  constitute  the  pabulum  of  repair  for 
wasting  tissues  in  the  higher  structures  of  the  body  ;  and  such, 
certainly,  it  has  been  proved,  is  a  physiological  fact.     Now,  if 
such  be  the  case,  the  inference  is  forced  upon  us,  that  it  cannot 
be  the  most  highly  developed  or  vitalized  element  of  the  blood. 
Moreover,  if  some  tissues  of  the  body  derive  their  nutriment  from 
other  elements  of  the  blood  than  fibrin,  it  must  be  conceded  that 
those  elements  may  possibly  supply  reparative  material  to  all. 
Fibrin,  so  long  exalted  as  the  highest  element  of  the  blood,  and 
as  the  one  which  directly  entered  into  the  construction  of  tissues, 
cannot  readily  bo  compelled  to  take  a  lower  place;  but  the  dis- 
coveries of  recent  physiologists  necessitate  that  humiliation.    But, 
although  fibrin  may  no  longer  occupy  so  proud  a  position  as  that 
of  being  a  reparative  material  for  ordinary  waste  and  decay,  it 
does  fulfil  a  no  less  important  duty  in  the  physical  economy; 


il 


COURSE    AND    TERMINATIONS    OF    INFLAMMATION.       49 


water,  albu- 
ood  be  taken 
rved  to  take 
on  ceases  to 

in  a  soluble 
parates  itself 
!  corpuscular 
clot  and  the 
f  the  fibrin. 
>ody  exhibits 
t  striking  of 
lation  of  the 
it  has  been 
igh.     Before 
lot  be  out  of 
•a  of  late  so 
jathologists; 
lan  system  ? 
!  of  opinion, 
id  organized 
h  exists  be- 
i^en  fabric," 
IS,  in  a  later 
•espect.    He 
f  repair  for 
;  and  such, 
;t.     Now,  if 
it  it  cannot 
'  the  blood, 
riinent  from 
needed  that 
mn\  to  all. 
)  blood,  and 
1  of  tissues, 
but  the  dis- 
ition.     But, 
tion  as  that 
id  decay,  it 
I  economy; 


namely,  that  of  supplying  material  for  extraordinary  repair.    The 
tissues  of  the  body  are  constantly  exposed  to  the  vicissitudes  of 
life— to  dieease,  and  to  accidents— and  nature  would  fail  to  main- 
tain her  reputation  as  a  conservator,  and  as  wise  to  provide  all 
things  necessary  for  life,  did  she  not  have  in  readiness  an  agent 
to  meet  the  .sudden  requirements  of  disease,  and  of  the  various 
disturbances  to  which  the  ^ssues  are  continually  exposed.     Here- 
in, I  would  venture  to  assert,  consists  the  importance  of  fibrin. 
This  is  the  special  object  for  which  it  exists.     It  is  by  this  that 
the  "  healing  process"  is  carried  on.    Of  this  I  shall  have  to  speak 
hereafter;  so  much,  however,  it  was  necessary  to  say  here,  that 
we  might  be  prepared  to  understand  that,  during  the  inflammatory 
process,  this  element  becomes  endowed  to  a  fuller  extent  with  those 
attributes  by  which  it  is  capable  of  acting  an  important  part :  no 
less,  indeed,  than  that  of  restoring  the  structure  inflamed  to  its 
normal  condition,  when  at  any  time  the  morbid  action  may  have 
ceased;  nay,  even  more,  that  of  arresting  the  inflammatory  pro- 
cess, and  thereafter  of  healing. 

During  the  inflammatory  process,  the  fibrin  is  said,  at  least  by 
some,  to  increase  in  quantity;  but  Paget  says  such  is  not  invaria- 
bly the  case.  Of  this  fact  there  is  no  doubt,  that  its  plasticity 
becomes  greater— that  its  vitality  is  increased  by  the  inflammatory 
action.  Coagulation  is  the  last  act  of  life  in  the  fibrin;  and  when 
it  refrains  from  this  act  for  a  time,  after  being  separated  from  the 
circulating  blood,  it  indicates  increased  vitality.  Now,  such  is 
observed  to  occur  in  the  fibrin  of  inflamed  blood;  but  when 
coagulation  does  take  place,  it  forms  a  mass  in  which  higher 
efi'orts  are  exhibited'  to  form  a  permanent  structure.  However, 
when  the  clot  is  entirely  removed  from  the  body,  it  has  its  limited 
period  of  what  might  be  called  its  rigor  mortis  (Simon),  after 
which  disintegration  of  its  substance  commences. 

The  blood  of  inflammation,  by  remaining  fluid  for  a  time  when 
drawn  into  a  vessel,  allows  certain  changes  to  take  place  in  the 
individual  elements  which  do  not  occur  in  healthy  blood,  when  it 
promi)tly  coagulates.  In  that  case  the  blood  coagulates,  the  several 
constituents  retaining  their  relationship  as  when  circulating  in  the 
body.  But  when  blood  stands  in  a  vessel  uncoagulated,  as  it  does 
in  inflammation,  the  more  solid  corpuscles  gravitate  toward  the 
bottom  of  the  vessel.     This  sinking  of  the  red  cornusrlos  !«  f..niH. 


^     1 
I  '     I- 


50 


PRINCIPLES    0:f    surgery. 


tated  by  a  peculiar  property  they  possess  of  attracting  one  another 
and  adhering  together  in  a  very  regular  manner  in  the  form  of 
rolls  (see  diagram).  The  consequence  of  this  action  is  that  fibrin 
alone  occupies  the  surface  of  the  mass.  The  natural  color  of  fibrin 
is  a  light  yellow,  and  the  surface  of  the  clot,  instead  of  presenting 
the  color  which  red  corpuscles  would  have  imparted  .to  it,  has  that 
hiff  hue  which  is  always  referred  to  in  connection  with  inflamma- 
tory blood. 

The  superficial  portion  of  the  fibrin  coagulates  first,  while  the 
lower  stratum  is  crowded  with  corpuscles.  These  corpuscles  in 
sinking  drag  upon  the  superior  solidifying  coat :  the  clot  at  its  cir- 
cumference being  attracted  by  cohesion  to  the  side  of  the  vessel, 
and  thereby  counteracting  the  weight  of  the  corpuscles,  the  cen- 
tral portion  will  be  principally  aff'ected  by  the  sinking  bodies.  In 
connection  with  this,  another  property  of  fibrin  is  exhibited;  that 
of  contraction  as  it  coagulates.  It  not  only  solidifies,  but  its 
volume  is  lessened  at  the  same  time.  It  contracts  into  a  narrower 
space,  squeezing  out  the  serum.  The  lower  stratum  is  the  last  to 
coagulate  and  contract,  and  the  result  is  that  the  surface  of  the 
buffy  coat  is  depressed  at  its  centre  or  cupped.  This  is  another 
characteristic  of  the  clot  of  inflammatory  blood.  In  the  coagula- 
tion of  inflammatory  blood,  according  to  Paget,  no  distinction  nor 
separation  can  be  detected  between  the  fibrin  and  the  white  cor- 
puscles. Virchow,  on  the  contrary,  observes,  that  "  on  looking  for 
the  colorless  corpuscles,  we  find  them  forming  a  separate  layer  at 
the  lower  border  of  the  buffy  coat.  This  peculiarity  is  simply  ex- 
plained by  the  diS'erent  specific  gravity  of  the  two  kinds  ol  blood 
corpuscles.  The  colorless  ones  are  always  light,  poor  in  solid 
matter,  and  very  delicate  in  structure,  whilst  the  red  ones  are  as 
heavy  as  lead  in  comparison,  owing  to  their  richness  in  hsematine." 

Such  is  the  state  of  blood  in  inflammation  resulting  from  the 
inflammatory  process.  At  first  the  blood  in  the  diseased  part  is 
alone  afl'ected :  this  contaminated  fluid  passes  away  by  collateral 
capillaries  into  the  circulation,  while  fresh  blood  takes  its  place  in 
the  aff'ected  part.  In  time  the  whole  volume  of  blood  participates 
in  the  morbid  changes.  These  changes,  to  repeat  somewhat,  con- 
sist in  an  increase  of  white  corpuscles,  which  are  perhaps  altered  ; 
also  a  relatively  increased  number  of  red  corpuscles,  which  are 
constantly  undergoing  changes  perhaps  of  degeneration,  or  are 


COURSE    AND    TER'lINATIONS    OF    INFLAMMATION.       51 


actually  dying ;  and  the  fibrin  possessing  increased  vitality  is  like- 
wise increased  in  quantity.  The  blood  is,  by  these  morbid  changes, 
rendered  irritating,  and,  as  it  passes  into  every  part  of  the  body, 
it  carries  the  seeds  of  inflammatory  disease  to  be  planted  in  tissues 
preternaturally  weak,  or  otherwise  predisposed  to  inflammation ; 
and  thus  it  is  that  through  the  agency  of  the  blood  inflammation 
may  extend  from  its  original  seat  to  parts  remote. 

Absorption  is  another  way  by  which  inflammation  may  be  said 
to  extend.  Apart  from  the  network  of  capillaries  is  a  system  of 
nutrient  vessels  (cells,  Virchow),  by  which,  no  doubt,  nutrition  is 
immediately  carried  on ;  and  through  which  extensive  territories, 
to  which  the  capillaries  approach  not,  are  supplied  with  nutritive 
juice.  Through  these  most  likely  are  conveyed  from  the  seat  of 
disease,  morbific  elements,  derived  either  from  the  blood  or  elements 
of  the  tissue.  These  may  find  entrance  into  the  lymphatic  sys- 
tem, and,  passing  along  to  the  glands,  be  there  arrested,  to  create 
disease ;  or  perhaps,  passing  onward,  ultimately  to  aff'ect  the  mass 
of  blood.  A  familiar  instance  of  extension  by  absorption  is 
afforded  in  the  inflammation  of  the  glans  penis  caused  by' specific 
poison.  In  this  case  the  poison  being  absorbed,  it  passes  to  the 
glands  of  the  groin,  which,  in  the  discharge  of  their  function  to 
keep  back  anything  which  is  deleterious  to  the  system,  arrest  the 
poison  ;  and  thereafter,  in  consequence,  themselves  become  affected. 
In  ordinary  inflammation  it  is  not  so  likely  to  extend  by  absorp- 
tion as  when  the  system  is  in  a  vitiated  condition ;  because  in  such 
a  case  morbid  elements  are  more  likely  to  be  formed  within  reach 
of  the  absorbents. 

Another  means  whereby  inflammation  extends  is  through  the 
agency  of  the  nerves.  We  have  discussed  the  subject  as  to  the 
part  taken  by  the  nerves  in  establishing  the  inflammatory  process, 
and  it  will  be  more  easily  understood  how  a  morbid  action  of  the 
nerves  may  cause  the  disease  to  extend.  There  are  nervous  cen- 
tres ;  and,  going  from  these,  are  nerves  which  divide  into  branches 
to  be  distributed  to  different  parts.  Now,  when  a  part  of  the  body 
is  inflamed,  not  only  the  nerves  thereof  are  deranged,  but  as  well 
the  nervous  centre  from  which  they  immediately  proceed.  And 
more  than  that ;  other  branches  proceeding  from  this  centre  par- 
ticipate to  some  extent  in  the  irritation.  The  action  and  reflex 
action  of  nerves  are  very  well  understood  in  lioalth  •  hut  when  the 


'!!i 


'll 


-  Ml 


52 


PRINCIPLES    OF    SURGERY. 


action  is  morbid,  when  the  ultimate  constituents  of  the  nerve- 
trunks  are  disarranged,  the  electrical  condition  thereof  disturbed, 
the  action  of  the  nerves  cannot  be  natural,  and  the  reflex  action 
is  likewise  unnatural.  Also  the  various  nerves  arising  and  pro- 
ceeding from  the  disturbed  centre  will  sympathize  in  the  general 
disturbance.  Hence  it  is  that  a  part  supplied  with  nerves  from  a 
centre  common  to  it  and  a  part  inflamed,  is  likely  to  become  aff"ected 
and  inflamed.  Hilton,  in  his  admirable  lectures  on  "  Rest,"  has 
fully  elucidated  this  question,  to  which  reference  will  be  more  fully 
made  in  connection  with  diseases  of  joints. 

These  are  the  several  ways  by  which  the  inflammation  may  ex- 
tend from  the  part  in  which  it  arises :  1st.  By  continuity ;  2d.  By 
contiguity ;  3d.  By  the  blood ;  4th.  By  absorption ;  5th.  By  the 
nerves. 


'■    :l    i 


CHAPTER    VI. 

The  Products  of  Inflammation :  1.  Serum ;  2.  Liquor  Sanguinis— Fibrin- 
Coagulation— Development— Hypertrophy,  True  and  False— Atrophy- 
Induration. 


Having  considered  the  ^Hnjlammatory  process,''  the  causes  of 
inflammation,  the  symptoms,  and,  in  connection  therewith,  the  di- 
agnosis, the  prognosis,  and  the  course  and  terminations  of  the  dis- 
ease into  either  resolution  or  into  further  morbid  displays  by  exten- 
sion, and  the  several  ways  by  which  it  may  take  place,  we  are 
fully  prepared  to  investigate  the  several  products  of  the  disease, 
or  the  results  of  the  inflammatory  action.  (Paget.) 

■  It  will  be  well  to  recall  to  mind  the  changes  which  take  place  in 
the  capillary  coats  during  the  inflammatory  process,  a  change  from 
healthy  nutrition  to  the  existence  of  morbid  products  of  diseased 
action.  To  illustrate,  let  us  take  a  common  cold  in  the  head.  The 
first  indication  is  a  watery  discharge  from  the  nose,  or  perhaps  a 
dryness  of  the  mucous  membrane,  causing  a  sensation  of  stuffiness. 
In  reality,  the  first  efi"ect  of  the  "  cold"  is  an  exalted  action  of  the 
mucus-secreting  glands,  by  which  there  is  a  copious  secretion  of 


THE  PRODUCTS  OF  INFLAMMATION. 


53 


healthy  material,  only  that  it  is  more  watery.  When  the  vessels 
contract  under  the  irritation  the  secretion  is  arrested,  and  the  dry 
stage  results.  Thereafter,  when  the  coats  relax  secretion  again 
takes  place ;  but  it  now  is  not  only  greater  in  quantity  but  also 
changed  in  character.  '  Everybody  has  experienced  a  catarrh  in 
the  head,  and  can  at  once  understand  the  illustration.  The  inflam- 
matory process  is  identical  in  other  tissues,  only  that  instead  of 
the  effects  being  exhibited  upon  a  mucous  surface  in  the  altered 
secretion  of  mucus,  they  present  themselves  in  the  transudation  of 
abnormal  material  into  the  structure  immediately  around  the  capil- 
laries ;  or,  in  other  words,  instead  of  transudation  of  those  ele- 
ments required  for  nutrition,  there  is,  as  a  result  of  the  inflamma- 
tion, transudation  of  material  which  cannot  become  in  any  case 
elements  of  ordinary  repair. 

The  first  product  to  be  noticed  is  serum.  This  may  often  be 
seen  when  there  is  o.ily  congestion,  before  the  vessels  "have  lost 
their  tone ;  but  it  is  when  they  become  much  relaxed  that  it  more 
particularly  abounds.  Very  often  in  what  seems  to  be  serum  only 
there  is  a  quantity  of  fibrin,  which  shows  a  tardy  disposition  to 
coagulate  even  when  separated  from  the  body.  As  a  general  thing, 
the  quantity  of  serum  is  greater  when  the  inflammation  is  more 
chronic,  and  when  the  action  is  acute,  fibrin  will  preponderate. 
The  exudation  of  serum  from  engorged  vessels  is  no  doubt  a  cura- 
tive effort ;  the  turgescence  is  often  thereby  very  much  relieved ; 
and  should  the  cause  of  irritation  then  cease  to  exist,  the  serum 
would  very  soon  be  reabsorbed. 

The  second  product  of  inflammation— liquor  sanguinis.  This,  it 
will  be  remembered,  is  composed  of  serum  and  fibrin.  But  the 
fibrin  now  receives  another  name.  Changed  in  character,  and 
probably  increased  in  quantity,  as  a  result  of  the  inflammation,  it 
takes  the  name  of  « inflammatory  lymph."  After  transuding,  the 
fibrin  remains  soluble  in  the  serum  for  some  time;  but  sooner  or 
later  it  begins  to  separate  from  it,  or  rather  the  serum  flows,  or  is 
pressed  away  by  the  coagulating  fibrin.  The  length  of  time  which 
elapses  before  it  thus  separates  into  its  component  parts— serum 
and  fibrin— varies;  it  may  take  place  at  once,  or  it  may  not  for 
some  length  of  time;  or  a  portion  of  the  fibrin  may  become  soli- 
dified while  another  portion  remain?  in  solution.  In  each  event 
It  is  not  difficult  to  observe  an  attempt  to  arrest  disease  or  re- 


'/'if 


I, 


M.ir 

;  p 


54 


PRINCIPLES    OF    SURGERY. 


Store  to  health.    Perhaps  further  observation  will  enable  us  to  say 
that  there  is  always  an  early  tendency  in  a  portion  of  it  to  stiffen 
around  the  small  vessels,  and  thus  by  external  support  assist  to 
prevent  over-distension  and  paralysis ;  and  further,  by  fixing  the 
tissue,  as  it  were,  to  secure  a  degree  of  rest  which  will  favor  re- 
covery,   Paget,  as  well  as  Virchow,  has  shown  that  a  very  long  time 
may  pass  away  while  the  fibrin  remains  in  solution  ;  indeed  it  would 
sometimes  almost  seem  that  exposure  to  air  alone  will  cause  the 
lymph  to  coagulate.     Coagulation,  it  will  be  remembered,  is  the 
last  act  of  life  in  fibrin  when  separated  from  the  body,  and  in  the 
main  it  must  be  considered  the  same  when  only  without  the  blood- 
vessels ;  hence  the  unwillingness  of  nature,  so  to  speak,  to  take  a 
step  by  which  the  fibrin  becomes  in  most  respects  a  foreign  body. 
While  in  solution,  or  only  solidified  in  a  limited  quantity,  it  can 
readily  be  absorbed ;  but  after  coagulation,  the  process  of  absorp- 
tion  is  necessarily  slow.     This  property,  therefore,  possessed  by 
inflammatory  lymph,  of  remaining  in  solution  for  a  longer  time 
than  natural  fibrin  does,  is  one  of  salutary  importance,  in  so  far 
as  recovery  is  concerned. 

Virchow,  in  his  cellular  pathology,  states  his  belief  that  there  is 
at  all  times  two  kinds  of  fibrin  in  the  system,— one  the  fibrin  of 
the  blood,  the  other  that  of  lymph  ;  and  that  it  is  the  latter  which 
manifests  this  tardiness  to  coagulate.     As  yet  we  may  feel  some 
unwillingness  to  receive  this  doctrine ;  but  should  further  experi- 
ments attest  the  truthfulness  thereof,  the  important  fact  would 
still  remain,  that  in  inflammatory  conditions  the  fibrin  which  so 
abundantly  transudes  is  tardy  in  coagulating ;  and  that,  while  the 
solidification  of  a  limited  quantity  will  prove  beneficial  by  affording 
external  support  to  distended  capillaries,  the  fluid  state  of  the 
greater  quantity  is  one  favorable  to  absorption,  on  the  cessation 
of  the  inflammatory  action.     And  still  more,  as  we  shall  see  when 
we  come  to  describe  the  healing  process,  this  fluid  condition  of  the 
fibrin  allows  the  formation  of  new  bloodvessels  to  take  place  in  its 
substance,  whereby  the  coagulated  fibrin  is  preserved  from  be- 
coming altogether  a  foreign  body,  and  by  which  it  is  afterwards 
gradually  removed,  as  natural  tissue  is  substituted  for  it.     The 
sacculated  and  tortuous  state  of  the  paralyzed  vessels  may  be  con- 
sidered a  first  step  toward  the  formation  of  these  new  vessels.     I 


THE  PRODUCTS  OF  INFLAMMATION. 


55 


will  risk  being  tedious,  to  endeavor  to  make  this  clearly  under- 
stood. 

Let  us  suppose  lymph  to  have  been  effused  between  two  capilla- 
ries (see  diagrams,  pages  28,  35),  which  are  dilated,  elongated,  and 
sacculated.    Now,  suppose  further,  the  inflammation  to  have  been  ar- 
rested, and  the  lymph  and  serum  about  to  be  separated  ;  the  latter  to 
be  absorbed,  the  former  to  attempt  organization.   Should  the  lymph 
coagulate  all  together,  it  will,  in  many  respects,  be  a  foreign  body, 
and  its  removal  be  difficult,  tedious,  or  impossible,  unless  by  sup- 
purative degeneration.     If,  however,  this  adventitious  matter  be 
supplied  with  vessels,  then  its  removal  will  be  more  easily  effected. 
Now  it  seems  to  be  by  those  sacculated  points  that  the  first  steps  are 
ordered  to  form  new  capillaries  which  shall  traverse  the  new  mate- 
rial.  These  sacculated  portions  continuing  to  dilate  and  extend,  be- 
come in  time  an  offshoot  of  the  vessel,  and  eventually  meet  another 
similar  offshoot  from  either  the  same  or  another  capillary.     The 
meeting  walls  break  down,  and  thus  a  complete  channel  is  made 
through  which  the  nutrient  fluid  at  once  begins  to  flow.     The  part 
which  this  new  vessel  plays  is  an  important  one :  by  it  no  doubt 
the  life  of  the  coagulated  lymph  is  prolonged ;  and  when  it  has 
served  its  purpose,  as  I  venture  to  think,  of  fixing  the  tissue,  and 
has  lived  its  comparatively  brief  life,  it  is  removed  in  the  same 
manner  as  natural  tissue  after  it  dies  or  wears  out.     Perhaps  it 
cannot  with  certainty  be  said  that  pseudo  tissue,  thus  organized 
and  sustained  by  blood,  entirely  fails  to  appropriate,  like  genuine 
tissues,  from  the  blood,  so  as  to  perpetuate  its  existence.     But  if 
it  possess  such  power  it  is  very  limited  in  degree,  while  the  tissue 
in  which  it  is  placed  will  exercise  a  more  potent  influence  in  assimi- 
lating, so  as  eventually  to  substitute  natural  for  the  unnatural 
elements.     Thus,  while  the  temporary  fabric  is  being  pulled  down, 
a  natural  structure  will  be  erected.    It  is  in  this  way  that  in  course 
of  time  a  part,  in  which  has  been,  as  a  result  of  inflammation,  an 
extensive  deposit  of  fibrin,  may  be  perfectly  restored  by  a  natural 
process  of  ordinary  repair.     There  are  several  facts  which  go  to 
support  this  view,  to  which  reference  will  be  made  when  speaking 
of  the  healing  process. 

Hypertrophy,  True  and  False.— But  instead  of  a  removal  being 
thus  gradually  and  fortunately  effected,  quite  a  contrary  result 
may  follow.     Although  inflammatory  action,  it  may  be  said,  has 


66 


PRINCIPLES    OF    SURGERY. 


Ill 


subsided,  there  sometimes  remains  a  degree  of  irritation  which  is 
due  to  the  adventitious  matter  before  mentioned.  On  account 
either  of  the  large  amount  of  fibrinous  deposit,  or  the  restless 
nature  of  the  tissue  or  organ  involved,  there  is  an  absence  of  that 
condition  of  the  part  which  is  necessary  for  absorption  to  take 
place.  Perhaps  the  coagulating  fibrin  within  the  part  embarrasses 
its  function ;  perhaps  the  function  of  the  part  is  such  as  almost 
to  preclude  the  possibility  of  that  repose  requisite  for  the  material 
to  be  absorbed.  The  consequence  of  either  is,  that  pathological 
irritation  continues,  and  a  continued  determination  of  blood  sup- 
plies more  than  is  required.  The  transudation  of  liquor  sanguinis 
steadily  in  limited  quantity  continues,  the  fibrin  of  which  con- 
stantly undergoes  changes  heretofore  described  ;  and  constant  ad- 
dition thus  is  made  to  the  previously  added  deposit.  From  time 
to  time  there  will  be  an  exacerbation  of  the  symptoms,  and  inflam- 
matory action  will  take  the  place  of  the  formative  process ;  this 
will  subside,  yet  recovery  cannot  follow,  but  a  renewal  of  the 
formative  process.  Instances  of  this  continued  irritation  may 
often  be  seen  after  inflammation  of  the  conjunctiva.  Here  the 
constant  motion  of  the  eyeball,  and  probably  the  exposure  of  the 
eye  to  light,  very  much  interferes  with  the  removal  by  absorption 
of  the  products  of  the  inflammation.  When  a  tissue  is  increased 
in  volume  in  this  way  it  is  the  seat  of  false  hypertrophy,  so  called 
in  contra-distinction  to  that  hypertrophy  where  the  volume  is 
increased  by  the  addition  of  the  natural  tissue. 

But  this  congestion  may  be  followed  by  true  hypertrophy.  The 
irritation  may  constitute  a  "physiological  stimulus,"  instead  of  a 
pathological  one,  and  the  result  is  that  the  part  grows.  Thus  wo 
see  that  one  immediate  product  of  inflammation  may  lead  to  other 
and  remote  products,  namely,  true  and  false  hypertrophy;  the 
former  being  charjicterizcd  by  the  addition  of  tissue  like  the  ori- 
ginal;  the  latter  by  the  gradual  addition  of  organizable  fibrin, 
which  becomes  intimately  incorporated  with  the  tissue  affected. 

Atrophy  of  Tissue.  —  Sometimes,  however,  instead  of  hyper- 
trophy, true  or  false,  resulting,  atrophy  supervenes  upon  the 
coagulation  of  the  transuded  fibrin.  This  can  bo  understood  when 
it  is  remembered  that  fibrin  in  process  of  coagulation  and  organi- 
zation always  contracts.  Now,  under  certain  circumstances,  this 
contraction  of  the  inflnmmatory  lymph  affects  the  nutrient  vessels, 


Sit 


THE    PRODUCTS    OF    INFLAMMATION. 


57 


—capillaries  and  larger  vessels.  By  pressing  upon  them,  the  ne- 
cessary supply  of  blood  is  cut  off,  and  the  nutrient  fluid  is  pressed 
out ;  nor  can  it  thereafter  enter  as  in  health ;  so  that  there  results 
a  disturbance  of  that  condition  necessary  for  normal  ordinary 
repair;  the  effect  of  which  is  that,  in  the  first  place,  the  tissue  is 
pressed  together,  whereby  its  volume  may  be  diminished;  and, 
secondly,  in  time,  from  want  of  nutrition,  the  part  actually  wastes 
away,  and  atrophy  is  the  sequel  of  the  primary  product. 

Induration  of  Tissue. — This  is  not  an  infrequent  result  of  in- 
flammation. The  plastic  material,  which  has  been  effused,  and 
which  has  become  organized  and  incorporated  with  the  tissue, 
occupies  the  interstices  thereof;  by  the  presence  of  which  the 
tissue  is  made  unusually  dense  and  hard — indurated.  This  con- 
dition may  exist  alone,  or  in  connection  with  either /aZse  hyper- 
trophy or, atrophy. 

So  far,  in  the  consideration  of  inflammatory  lymph,  I  have 
spoken  only  of  those  changes  which  exhibit  attempts,  more  or  less 
successful,  to  become  organized,  and  to  cure.  But  it  has  been 
seen  that,  instead  of  the  efforts  to  restore  being  always  successful, 
there  frequently  arises  therefrom  other  pathological  conditions, 
namely,  hypertrophy,  atrophy,  and  induration. 


CHAPTER    VII. 


Products  of  Inflammntion— Dogpuprntion  of  Lymph— Corpusculnr  and  Fibrin- 
ous Elements  — Cause  of  eadi  — 1.  Pus:  How  formed)  Different  ways 
found— 1.  Alisci'ss;  2.  Diffused;  3.  Upon  tlio  Surfiice— 2d  Form  of  Doge- 
ncriition  of  Pus  — Fatty;  Jtd.  Calcareous;  4th.  Pigmental  — Blood  as  a 
Product— Changed  Mucus, 


Hi 


I.      !| 


But  inflammatory  lymph  does  not  always  show  this  tendency 
to  organize — to  become  developed.'  In  consequence  either  of  the 
intonsity  of  the  inflammatory  action,  or  the  state  of  the  lymph 
itself,  it  Hometimes  degenerates — descends  to  a  lower  state  of  exist- 
ence. As  a  result  of  inflauunation,  the  most  ordinary  form  of 
dejxcneration  is  into  pus. 


«) 


/( 


58 


PRINCIPLES    OF    SURGERY. 


Inflammatory  lymph  may  be  divided  into  two  kinds,  one  of 
which  is  characterized  by  a  tendency  to  organize,  and  the  other 
to  degenerate  into  pus.  (Paget.)  Or  I  may  say  that  the  fibrin  of 
the  liquor  sanguinis  is  composed  of  two  elements:  one  is  a  fibrin- 
ous element,  the  other  corpuscular.  These  may  exist  in  equal 
proportion,  or  one  may  be  in  excess.  When  the  fibrinous  element 
is  in  excess,  there  will  be  a  tendency  to  organize,  and  a  disposition 
to  what  is  called  the  adhesive  form  of  inflammation.  When  the 
corpuscular  element  abounds,  the  tendency  to  degenerate  into^us 
tvill  exist ;  this  constitutes  suppurative  inflammation.  There  are 
three  conditions,  to  one  or  more  of  which  the  distinctive  character 
of  the  fibrin  may  be  due:  1st,  the  state  of  the  blood;  2d,  the 
character  of  the  tissue  involved ;  3d,  the  intensity  of  the  inflam- 
mation, or  the  exciting  cause. 

The  blood  of  a  healthy  subject,  in  inflammation,  always  possesses 
more  of  the  fibrinous  element  than  that  of  one  who  is  unhealthy; 
and  especially  of  a  scrofulous  subject,  or  one  whose  system  is 
reduced  below  par.  And  there  are  certain  conditions  of  the  sys- 
tem, or  blood,  in  which  the  corpuscles  are  both  numerous  and  sus- 
ceptible of  degeneration,  whenever  inflammation  may  arise. 

In  the  second  place,  certain  tissues,  Avhen  inflamed,  always  pro- 
duce fibrinous  lymph;  at  least  it  is  largely  in  excess;  for  instance, 
the  fibrous  tissues  and  serous  membranes  generally.  It  is  one  of 
the  facts  earliest  learned  by  the  student,  that  in  inflammation  of 
the  serous  membranes  adhesions  are  likely  to  form  between  two 
surfaces  which  may  come  together.  On  the  contrary,  wlion  the 
skin,  or  mucous  membrane,  or  cellular  tissue,  is  inflamed,  the  lymph 
resulting  is  composed  more  of  the  corpuscular  element ;  and  hence 
the  fact  that  pus  is  a  probable  product  of  the  disease,  as  in  ery- 
sipelas, &c.  When  the  lung  is  inflamed,  in  the  resulting  lymph 
these  two  elements  are  about  equal ;  but  Paget  says  that  tlie  cor- 
puscles show  a  marked  tendency  to  degenerate.  In  the  brain, 
when  in  flamed,  there  is  rather  a  tendency  to  the  formation  of 
corpuscular  lymph. 

I  wish  here  to  refer  particularly  to  tlie  interesting  and  important 
fact,  one  which  will  obtain  more  attention  hereafter,  that,  in  each 
tissue  and  organ  of  the  body,  such  lympli  is  elaborated,  in  con- 
nection with  the  inflammation,  as  will  best  servo  a  curative  pur- 
pose. ( Vide  Healing  Process.) 


THE    PRODUCTS    OF    INFLAMMATION. 


69 


In  the  third  place ;  the  intensity  of  the  inflammation,  to  a  cer- 
tain extent,  modifies  the  character  of  the  lymph.  The  greater  the 
intensity,  as  a  general  thing,  the  larger  the  proportion  of  the 
fibrinous  element.  This  is  equally  true  in  all  tissues,  whatever 
may  be  the  controlling  influence  they  have  as  such. 

One  of  the  above  conditions  may  modify  another ;  while,  if  they 
all  act  in  harmony,  either  to  favor  the  formation  of  the  fibrinous 
element,  or  the  corpuscular,  the  effect  will  be  correspondingly 
great.  For  instance,  in  diphtheritic  inflammation,  although  a 
mucous  tissue  is  concerned,  yet,  owing  to  the  intense  nature  of 
the  disease,  the  fibrinous  element  preponderates,  so  that  a  false 
membrane,  such  as  forms  upon  serous  membranes,  is  produced.  On 
the  otlior  hand,  when  inflammation  arises  in  the  serous  membrane 
of  an  unhealthy  person,  or  when  the  inflammation  be  asthenic, 
then,  instead  of  adhesions  taking  place,  pus  may  be  expected  to 
form,  indicating  a  want  of  the  fibrinous  constituent  of  the  lymph. 
Such,  then,  are  the  circumstances  which  give  to  the  inflammatory 
lymph  either  a  fibrinous  or  corpuscular  character.  And  it  is  well 
to  remark  here,  that  these  circumstances  must  be  duly  taken  into 
con.sideration,  when  the  surgeon  is  called  upon  to  form  a  diagnosia 
and  prognom. 

Pus. — As  before  said,  the  most  frequent  form  of  degeneration 
of  lymph  is  into  pus.  This  fluid  presents  the  following  character- 
istics.    It  appears  to  the  naked  eye  as  a  creamy,  thick,  opaque, 


V 


and  homogeneous  fluid ;  communicates  an  unctuous  feeling  when 
rubbed  between  the  fingers;  is  a  yellow  or  whity-yellow  tint;  sweet- 
ish, or  insipid ;  and,  while  warm,  gives  off"  a  peculiar,  mawkish  smell. 
Its  specific  gravity  is  1030-1083.  If  allowed  to  stand  some  time 
in  a  tall,  narrow  glass,  the  fluid  separates  into  a  thickish  sediment, 
more  or  less  abundant,  and  a  supernatant  serum.  This  serum, 
according  to  Vogel,  is  identical  with  the  scrum  of  the  blood,  con- 
taining much  albumen,  extractive  and  saline  matters,  and  fat. 
The  reaction  is  alkaline;  but  it  readily  becomes  acid,  from  the 
generation  of  an  acid,  wliich  is  commonly  supposed  to  bo  the 


!      '        'fi 


60 


PRINCIPLES    OP    SURGERY. 


nr 


lactic.     In  some  cases,  however,  according  to  Walshe,  it  has  an 
acid  reaction  even  at  the  time  of  its  formation,     '<  The  sediment 
consists  almost  entirely  of  small  organized  corpuscles,  the  well- 
known  pus-globules.     These  are  of  spherical  form,  have  a  well- 
defined  contour,  formed  by  a  distinct  homogeneous  envelop,  inclos- 
ing a  soft,  granulous  substance,  and  a  varying  number  of  nuclear 
corpuscles.     These  are,  in  well-formed  pus-globules,  for  the  most 
part  concealed  by  the  surrounding  substance;  but,  in  the  younger 
cells,  even  of  healthy  pus,  and  in  all  those  of  pus  of  an  inferior 
kind,  they  are  easily  perceptible,  even  without  the  aid  of  acetic 
acid.     Occasionally,  a  single  nucleus  exists;  bnt  more  commonly 
it  is  made  up  of  two,  three,  four,  or  even  five  large  granules.    The 
single  nuclei  are  always  the  largest,  and  indicate,  as  we  conceive, 
the  most  perfect  kind  of  development."     <'  The  nucleus  is  seated 
on  the  envelop,  or  is  parietal,  as  it  is  termed.     Its  diameter  is 
about  gg'gg  in.;  that  of  the  entire  pus-globule  about  -^^^^  in." 
(Jones  and  Sieveking's  Pathological  Anatomy.)     Paget  calls  the 
liquid  in  which  the  pus-cells  are  suspended  the  liquor  puris ;  and 
remarks,  that  "in  the  pus  produced  during  healthy  granulation, 
no  other  materials  than  these  may  be  found."     "But,  often,  mi- 
nute clear  particles,  not  more  than  ^  gjgjj  of  an  inch  in  diameter, 
are  mingled  with  the  pus-cells,  to  which  they  seem  to  have  some 
relation  as  rudiments.    And  when  the  process  deviates  from  health, 
we  find  not  only  variations  in  the  pus-cells,  but  multiform  mixtures 
of  witlicred  cells,  molecular  and  fatty  matter,  free,  or  escaped  and 
shrivelled  nuclei,  blood-corpuscles,  fragments  of  granular  substance 
like  shreds  of  fibrin,  and  other  materials.    All  these  indicate  de- 
fects or  diseases  of  pus."     "A  caution  is  necessary  against  a  very 
possible  error  which  even  practised  observers  have  committed, 
viz.,  that  of  mistaking  the  colorless  corpuscles  of  the  blood  for  pus- 
globules.     The  two  bodies  are  very  much  alike,  but  the  blood-cor- 
puscle is  somewhat  smaller,  generally  more  finely  granular,  and 
with  rather  less  definite  contour.     The  interior  nuclei  of  both  are 
identical."  (Jones  and  Sieveking.)     But  Virchow  says  that  "we 
can  never  say  with  certainty  off-hand  whether  we  have  to  deal  with 
colorless  blood-  or  pus-corpuscles." 

Such  are  the  characteristics  of  pus,  as  observed  with  and  without 
the  aid  of  the  microscope. 

The  circumstances  which  attend  degeneration  of  lymph  into  pus, 


THE    PRODUCTS    OP    INFLAMMATION. 


61 


or  which  turn  the  process  from  organization  into  one  of  degenera- 
tion, may  now  be  more  fully  considered.  It  will  be  remembered 
that  it  is  a  prerequisite  for  development  and  organization  of  lymph 
to  have  a  cessation  of  the  inflammatory  action ;  and  furthermore 
let  it  be  stated  that  the  inflammation  must  not  have  been  in  active 
progress  beyond  a  certain  time,  which  length  of  time  will  vary  ac- 
cording to  circumstances  hereafter  to  be  fully  described.  But,  if 
the  exciting  cause  of  the  inflammation  continue  to  act,  then  there 
is  entered  upon  a  new  stage  of  the  disease,  another  step  in  the 
inflammatory  process  is  taken,  and  what  has  been  called  true  in- 
flammation is  attained. 

Following  the  stagnation  of  blood  and  the  free  exudation  of 
liquor  sanguinis,  there  is,  in  the  part  immediately  concerned,  in- 
stead of  coagulation  of  the  fibrin  and  a  squeezing  out  of  the  serum, 
quite  a  different  procedure  manifested  in  this  fluid.  The  corpus- 
cles of  the  fibrin  undergo  perhaps,  I  might  say,  a  retrograde  devel- 
opment; in  reality,  it  is  a  degeneration.  In  this  change  the 
fibrinous  element  of  the  lymph  participates.  The  palpable  evi- 
dence of  this  change  is  the  existence  of  the  cream-like  fluid  pus, 
instead  of  the  plastic  buff'-colored  fibrin.  Before  degeneration  sets 
in,  perhaps  a  separation  more  or  less  complete  had  taken  place  be- 
tween the  fibrin  and  serum.  Indeed,  there  is  proof  that  a  large 
quantity  of  lymph  may  simply  coagulate,  and  remain  so  for  even 
a  few  days,  and  then  degenerate.  In  this  latter  case  there  is  evi- 
dently a  liquefactive,  so  called,  degeneration.  Take  the  surface  of 
a  wound  when  adhesion  has  failed  to  take  place  ;  after  a  few  days 
it  will  be  found  covered  with  pus.  Again,  take  a  hard  swelling 
due  to  extensive  eff'usion  of  lymph  which  has  coagulated ;  it  is  at 
first  hard  and  unyielding,  but  in  a  limited  number  of  hours,  as 
every  observing  surgeon  has  seen,  this  hard  swelling  will  have 
become  soft  and  fluctuating.  That  which  was  solidified  lymph  is 
now  a  fluid  pus,  and  that  without  the  addition  of  any  fluid  fibrin. 
While  this  degeneration  of  inflammatory  lymph  into  pus  is  in  pro- 
gress, the  cause  of  the  action  continuing,  the  inflammation  is  ex- 
tending, and  where  a  short  time  before  was  congestion,  is  now 
stagnation ;  and  more  remote  parts  not  previously  engaged  will 
now  be  rapidly  beginning  to  participate  in  the  morbid  action.  The 
ayuiptoms  which  generally  6haracterizo  the  formation  of  pus  will, 


'I 


?.t 


^^;:flsrtf 


'.f 


62 


PRINCIPLES    OP    SURGERY. 


in  another  place,  be  considered,  as  well  as  the  treatment  to  be  pur- 
sued. 

It  has  been  shown  that  in  the  organization  of  lymph  there  is 
displayed  a  wise  and  salutary  effort  on  the  part  of  nature  to  repair 
the  injury  which  the  part  had  sustained,  the  cause  of  the  disease 
having  been  removed.     And  also,  when  pus  is  generated,  although 
it  is  a  degeneration,  a  process  with  a  tendency  directly  opposite 
to  that  of  organization,  yet  it  is  nevertheless  a  means  equally  wise 
to  effect  a  cure.     The  disease  having  lasted  for  a  longer  time,  and 
the  effects  having  been  correspondingly  aggravated,  other  and 
more  complex  steps  are  required  to  restore  the  part,  and  even 
more  than  this,  to  prepare  the  way  for  successful  restoration.     It 
is  a  necessity  that  the  cause  of  the  disease  should  be  removed;  and 
when,  for  instance,  that  cause  is  the  presence  of  a  foreign  body  in 
the  tissue,  then  the  formation  of  pus  and  the  subsequent  softening 
of  tissue  has  the  effect  of  opening  a  channel  by  which  the  foreign 
body  will  be  expelled.     It  is  nature's  method  of  getting  rid  of  a 
foreign  body,  a  process  to  which  I  shall  have  hereafter  to  refer. 
Again,  when  pus  forms  upon  the  surface  of  a  wound  it  constitutes 
the  most  suitable  covering,  one,  indeed,  which  cannot  be  imitated, 
to  allow  the  healing,  which  will  take  place  by  granulation.     And 
again,  when  it  is  seen  upon  a  mucous  surface,  it  will  be  found  to 
protect  that  membrane  from  irritation,  to  some  extent,  at  least. 
And  lastly,  although  the  pus  may  not  be  required  for  any  of  the 
above-mentioned  purposes  to  act  as  a  remedial  measure,  yet,  as 
lymph  which  has  been  transuded,  and  which  is  incapable  of  removal 
by  absorption  while  in  that  condition,  it  pursues  the  next  best 
course  to  make  its  exit  from  the  body,  and  consequently  undergoes 
a  liquefactive  change.     Being  found  in  the  form  of  pus,  it  may,  by 
pressure,  cause  absorption  of  the  tissue,  and  find  its  way  gradually 
to  the  surface,  and  escape  in  a  bulk,  or  it  may,  under  favorable 
circumstances,  be  absorbed.     The  precise  method  by  which  the 
former  takes  place  will  be  dwelt  upon  in  connection  with  abscess. 
The  method  adopted  to  secure  absorption  of  the  pus-matter  will 
now  be  briefly  noticed. 

Pus  as  such  cannot  be  absorbed ;  the  cells  are  bodies  of  too 
largo  a  size  to  be  capable  of  entering  the  absorbent  system.  It 
is,  therefore,  necessary  for  some  further  change  to  take  place  be- 


k 


THE    PRODUCTS    OF    INFLAMMATION. 


63 


fore  this  product  of  inflammation  can  be  removed  by  the  process 
of  absorption. 

In  the  process  of  degeneration  it  has  been  observed  that  the 
corpuscles,  which  in  the  lymph  were  like  the  white  corpuscles  of 
the  blood  as  well  as  the  primordial  cell,  begin  to  increase  in  size. 
They  "present  a  gradual  increase  of  shining,  black-edged  parti- 
cles, like  minute  oil-drops,  which  accumulate  in  the  cell-cavity,  and 
increase  in  number,  and  sometimes  in  size,  also,  till  they  nearly 
fill  it.  The  fatty  nature  of  these  particles  is  proved  by  their  solu- 
bility in  ether,  and  their  accumulation  is  attended  with  a  trradual 
enlargement  of  the  cell,  which  also  assumes  a  more  oval  form. 
Moreover,  while  the  fatty  matter  accumulates,  the  rest  of  the  con- 
tents of  the  cell  become  very  clear,  so  that  all  the  interspaces  be- 
tween the  particles  are  quite  transparent;  and,  coincidently  with 
all  these,  changes,  the  nucleus,  if  any  had  been  formed,  gradually 
fades  and  disappears,  and  the  cell-wall  becomes  less  and  less  dis- 
tinct." (Pi  get.)    Finally,  the  microscope  can  no  longer  detect  the 


cell  wall ;  indeed,  it  is  dissolved,  or  has  undergone  such  changes 
as  will  permit  it  to  be  taken  away  by  the  absorbents.  These  mani- 
festations of  nature  arc  not  only  interesting,  but  they  indicate  as 
well  in  many  respects  the  course  of  treatment  which  has  to  be 
pursued  by  the  surgeon  in  the  different  stages  of  the  inflammatory 
process. 

Different  tvai/s  in  ivhich  pus  may  he  found: 

The  1st.  In  the  form  of  an  abscess,  in  which  case  it  is  circum- 
scribed. 

The  2d.  When  it  is  diffused  in  the  tissue,  and  without  any  defi- 
nite boundary. 

The  8d.  When  it  is  poured  out  upon  a  free  surface,  as  the  skin 
or  mucous  membrane.   (Paget.) 

The  peculiarity  of  each  and  the  treatment  will  be  taken  up  in 
duo  time. 

While  degeneration  into  pus  is  by  far  the  most  frequent  in  oc- 


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64 


PRINCIPLES    OP    SURGERY. 


currence,  there  are  others  which  require  our  attention.  Both  the 
fibrinous  and  corpuscular  elements  may  undergo  several  forms  of 
degeneration.  The  first  is  where  they  wither,  become  dry,  hard, 
horny,  the  cells  "  are  collapsed,  shrivelled,  wrinkled,  glistening,' 
and  altogether  irregular  in  size  and  form."  (Paget.) 


The  second  form  of  degeneration  is,  where  an  essentially  fatty 
change  takes  place.  In  the  fibrinous  portion  will  be  seen  gradually 
collecting  minute  drops  of  oil,  and  the  corpuscles  undergo  a  transi- 
tion into  what  is  called  granule-cells,  or  the  inflammatory  globules 
of  Gluge.  "  This  method  of  degeneration,"  says  Paget,  "  appears 
peculiarly  apt  to  occur  in  the  inflammations  of  certain  organs,  as 
especially  the  lungs,  the  brain,  and  spinal  cord ;  but  it  may  be 
found  occasionally  prevalent  in  the  lymph  of  nearly  all  the  other 
parts,  and  in  the  granulations  forming  the  walls  of  abscesses  or  of 
fistulse." 

^  The  third  form  of  degeneration  is  the  calcareous.     It  is  occa- 
sionally seen  in  the  arteries  and  veins. 

The  fourth  is  called  pigmental  degeneration ;  sometimes  observed 
in  the  product  of  peritonitis. 

Having  considered  the  character  of  inflammatory  l^mph,  and  the 
widely  difi-erent  changes  which  may  mark  its  history  until  it  ceases 
to  act  a  part  in  the  economy,  I  will  proceed  in  the  consideration 
of  the  products  of  inflammation. 

Blood  as  a  Product  of  Inflammation.— TYn^  may  be  regarded 
rather  as  an  accidental  product  than  as  a  constant  one,  except, 
perhaps,  in  pneumonia,  in  which  disease  it  is  almost  always  pre- 
sent, and  gives  to  the  sputa  the  characteristic  rust  color.  But  at 
any  time  after  the  coats  of  the  vessel  have  become  paralyzed,  they 
may  be  actually  ruptured  ho  as  to  allow  the  blood  to  be  extrava- 
sated.  It  must  be  distinctly  understood  that  a  red  corpuscle  can- 
not  get  without  the  vascular  system,  unless  there  is  a  distinct  rup- 
ture of  the  coats.     The  transudation  may  be  even  highly  colored, 


TKEATMENT    OF    INFLAMMATION. 


65 


but  It  IS  due  to  the  coloring  matter  of  broken-down  corpusclea 
which  has  transuded  with  the  serum.  Again,  in  the  attempt  to 
form  new  bloodvessels,  the  offshoot  may  burst  and  the  blood  escape 
mto  the  organizing  fibrin.  So  it  will  be  seen  that  in  general 
inflammation  it  is  but  an  accidental  product.  With  regard  to 
treatment,  it  requires  no  particular  consideration. 

Changed  Mucus  as  a  Product  of  Inflammation.— Yihm  inflam- 
mation  arises  in  a  mucous  membrane,  as  already  stated,  the  natu- 
ral  secretion  is  at  first  exalted  and  then  suppressed ;  subsequently 
m  returning,  it  is  quite  altered  in  character  and  quantity.  In 
addition  to  the  mucus  is  seen,  under  the  microscope,  epithelial  par- 
tides,  more  or  less  degenerate,  and  "  materials  which  closely  resem- 
ble, if  they  are  not  identical,  with  the  lymph-products  of  inflam- 
mation  in  other  parts.  I  am,  indeed,  disposed  to  think  that  we 
should  not  draw  too  strong  a  contrast  between  the  inflammatory 
products  of  mucous  membranes  and  those  of  serous  membranes 
and  other  parts,  except  in  relation  to  the  material  with  which  in 
the  several  cases  they  are  mixed."  (Paget.) 

The  foregoing  are  the  immediate  products  of  inflammation. 
Ihere  are  other  surgical  affections  which  are  often  designated  pro- 
ducts  also;  these  are  ulceration,  sloughing,  and  gangrene;  but 
they,  with  other  diseases,  will  be  treated  under  the  head  of  Dis- 
eases arising  out  of  Inflammation. 


CHAPTER    VIII. 

Treatment  of  Inflammation-In  its  First  Steps-1.  Nature  as  a  Guide  " 
Prevention  of  Further  I  .ress.  8.  Sedatives.  4.  Cold.  5.  Heat.  6  Stimu- 
lants.    7.  Astringents. 

There  are  two  things  which  ought  to  be  constantly  borne  in 
mind  by  the  surgeon  in  the  treatment  of  this  disease;  the  first  of 
which  is,  that  in  the  inflammatory  process  itself,  and  at  each  step 
of  the  process,  nature  seems  to  be  making  efforts  to  cure,  and  that 
many  of  the  phenomena  of  the  disease  are  results  of  those  efforts. 
To  this  subject  I  beg  leave  to  direct  especial  attention.     Writers 


'Tl 

\  i 

:  I 

!!  ' 
J !  \ 

^ 

M 

\m 
II 


66 


PRINOIPLES    OP    SURGERY. 


on  surgery  have  been  accustomed  for  so  long  time  to  speak  of  the 
phenomena  of  inflammation,  and  indeed  of  all  surgical  affections, 
as  purely  symptoms  of  disease,  that  it  is  next  to  impossible  to  dis- 
associate the  indications  therefrom,  and  to  regard  them  instead  as 
exhibitions  of  the  admirable  workings  of  nature  to  stay  disease, 
to  remove  the  cause  thereof,  and  to  eff"ect  a  cure.  I  have  thus 
far,  in  considering  the  inflammatory  process,  taken  occasion,  from 
time  to  time,  to  point  out  these  kind  doings  of  nature.  And  unless 
the  student  starts  with  the  perfect  understanding  that  he  can  only 
assist  nature,  and  that  in  all  he  does  he  should  take  counsel  with 
her,  and  follow  her  superior  guidance,  he  will  not,  I  unhesitatingly 
aflSrm,  be  prepared  to  render  that  wise  and  judicious  assistance 
which  enlightened  surgical  science  justly  expects  at  his  hands. 

The  second  point,  and  one  of  almost  equal  importance  with  the 
above,  is  to  endeavor  to  have  a  distinct  understanding  as  to  the 
stage  of  the  inflammatory  process  at  the  time  he  is  called  upon  to 
treat  the  case.  This  is  so  obviously  necessary  that  it  may  be 
deemed  useless  to  refer  to  it ;  yet  I  am  sure  it  will  be  found  that 
some  writers  and  many  practitioners  treat  inflammation  without 
any  reference  to  this  consideration.  Having  diagnosed  the  disease 
as  that  of  inflammation,  they  proceed  to  treat  it  according  to  pre- 
scribed rules,  forgetting,  in  their  routine  practice,  that  the  treat- 
ment  suitable  for  one  stage  of  the  process  is  quite  unsuitable  for 
another ;  that  what  may  be  a  remedy  one  day  may  upon  the  next 
aggravate  the  disease.  Now  these  two  considerations,  I  think, 
stand  foremost,  and  ought  never  be  lost  sight  of. 

The  next  thing  for  the  surgeon  to  consider  is.  How  much  can  I 
do  to  prevent  disease  ?  Indeed  he  may  now  and  then  be  called  in  ' 
at  a  sufficiently  early  hour  to  be  able  to  break  the  chain  which 
leads  from  tlie  exciting  cause  to  the  first  stage — before  physiologi- 
cal action  has  been  superseded  by  pathological ;  or,  if  the  disease 
has  already  been  established,  he  may  yet  succeed  in  averting  the 
second  or  some  succeeding  step  in  the  inflammatory  process.  Then 
he  will  ask  himself  the  question,  What  are  nature's  cflTorts  under 
the  present  circumstances,  and  how  far  can  I  assist  her  ? 

To  a  just  appreciation  of  the  case,  and  in  order  to  arrive  at  cor- 
rect conclusions  concerning  the  foregoing  questions,  a  knowledge 
of  the  individual  constitution  will  be  indispensable,  and  should  as 
far  as  possible  be  obtained.     As  well,  and  of  equal  importance  it 


1 
I 


TREATMENT    OP    INFLAMMATION. 


67 


■rive  at  cor- 


IS  to  ascertain  what  were  the  predisposing  and  determining  causes 
of  tne  disease  and  the  relative  importance  of  each.  In  connection 
with  this,  the  surgeon  should  duly  weigh  the  circumstances  of  the 
patient  and  the  evils  connected  therewith  which  he  will  have  to 
combat  and  to  what  extent  can  be  secured  that  rest  of  mind  and  of 
body  which  will  so  much  conduce  to  a  favorable  termination.  It 
will  also  be  desirable  to  consider  what  are  his  surroundings,  his 
posi  ion  will  he  have  good  nursing,  comforts,  necessaries,  anct  ;hat 
are  his  desires  and  his  degree  of  contentment 

The  primary  cause  of  the  disease  will  not  always  receive  the 
first  attention.  When  constitutional,  it  will  always  receive  how- 
ever, an  early  attention;  but  when  it  is  local,  it  may  alreadl  have 
parsed  away.  The  great,  the  chief  thing  is  to  get  at  the  cau^e  of 
the  cont^nuance  of  the  inflammation,  the  principal  acting  cause  of 
extension  of  the  disease,  and  to  attack  it.  y        »«  or 

Instead  of  taking  one  by  one  the  various  medicines  which  may 
advantageously  be  used  in  the  treatment  of  inflammation,  it  will 
I  think,  be  preferable  to  commence  at  the  beginning  of  the  "  pro 
cess ;    at  least  at  that  point  where  nature  is  yielding  to  overpower- 
ing  influences.  ^  &  ^  puvyci 

Imagine,  then  an  affected  part,  into  which  the  Hood  is  rushin. 
w,th  mcreasmg  force.  The  small  vessels  are  engorged  to  such  af 
extent  that  over-distension  has  almost  resulted.  Theyhave  "  !t  d 
to  rece,ve  the  increased  flow  of  blood,  but  the  rush  ha  been  o 
great,  and  a  contraction  has  followed  more  or  less  spasmodic.    Then 

h  !o  i  V      \  I    "^  '''°"'"  '™'  *«'•  '"•"'^  stagnation  of 

Mood  has  a  most  resulted,  and,  should  it  ensue,  inflammation  wiH 
h   really  estabhshed.    Now,  under  such  circu^tances,  what  1     ' 

Ltrat  „°  T  "'     °i  ™""'  ''  P"'^'"^'  *»  -ci  ing    ause 
1.0U  d  at  once  be  removed.     But  the  first  class  of  remedied  which 

IwJl  no  ,ee  as  suitable  to  this  stage  of  the  inflammatory  prL    "  is 

SAU«>  as  a  reneiy  for  inflammalion.-lS.,,,  wdl  fiTr 

hea  ng  proc  s,  is  consummated.     And  sedatives  may  have  the 

n^heCrof'm   l;  "'"""'  -rve,,  whereby  an  essential  lL\ 
m  the  chain  of  morbific  causes  may  be  broken.     It  is  by  irritation 

V   h!  "Tr  '""  *"  ■"'""'°«'"»'  ™"*«»"  -  initiated,    ndt°" 
by  thcr  disturbance  and  from  the  pressure  made  upon  them  tliat 


I  'I 
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68 


PRINCIPLES    OF    SURGERY. 


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<  I    t 


the  pain  is  continued  and  the  disease  extended.  Therefore,  tu 
soothe  them  at  any  time  is  to  remove  the  most  important  means  of 
disease.  By  so  doing  we  are  only  imitating  the  efforts  made  by 
nature  to  relieve  irritation  by  fixing  the  parts  involved  so  that  they 
may  be  in  a  state  of  repose.  There  can,  indeed,  be  but  little 
doubt  that  the  tendency  to  adhesion  which  characterizes  inflamma- 
tion of  the  serous  membranes  is,  by  preventing  motion  of  the  irri- 
tated parts,  calculated  to  secure  rest.  It  is  a  fact  most  important 
to  know  that  a  full  dose  of  opium  will  often  arrest  inflammatory 
action  in  the  abdomen  by  securing  rest  to  the  viscera ;  and  thus 
will  nature,  when  unassisted  by  art,  attempt,  by  forming  adhe- 
sions, to  obtain  the  same  thing. 

Anything  which  will  alleviate  irritated  periphery,  or  pressed- 
upon  nerves,  will  tend  to  eff"ect  a  cure.  If  the  part  be  kept  at  rest 
much  is  gained.  But  there  are  agents  which  will,  often  against 
great  obstacles,  assist  in  securing  the  desired  end.  The  first  seda- 
tive to  be  mentioned  is 

Cold. — It  is  generally  applied  to  the  part  in  the  form  of  cold 
water,  and  it  is  a  most  valuable  remedy,  not  alone  because  of  its 
actual  virtue,  but,  as  well,  because  it  is  so  easily  obtained.  Ex- 
treme cold  is  a  powerful  sedative,  especially  when  applied  with 
diligence.  If  applied  to  a  part  in  health  it  will  interfere  with 
nutrition ;  and,  when  applied  to  an  inflamed  region,  it  will  lessen 
the  morbid  action  therein.  The  object  is  to  lower  the  temperature 
of  the  part  not  simply  to  that  degree  which  is  natural,  but  to  a  de- 
gree even  below  it.  The  coldness  of  the  water  and  the  evapora- 
tion act  together  in  securing  this  reduction  of  temperature.  To 
carry  out  this  indication  the  water  must  be  very  cold,  or  there 
must  be  such  an  arrangement  as  will  favor  evaporation,  and,  if 
possible,  both.  The  following  method  of  applying  cold  I  can, 
after  not  a  little  experience,  strongly  recommend.  Take  a  piece 
of  thin  old  cotton  or  muslin,  folded  only  once,  and,  having  dipped 
it  in  a  vessel  of  cold  water,  apply  it  to  the  part.  It  will  be  neces- 
sary, according  to  my  own  experience,  to  give  very  explicit  in- 
structions to  the  nurse  about  the  cloth,  as  to  thickness,  &c.,  other- 
wise most  likely  there  will  be  used  a  piece  folded  several  times. 
And  this,  instead  of  being  frequently  dipped  in  the  water,  will 
be  allowed  to  remain  for  a  long  time.  The  result  will  be  a  steam- 
ing cloth  upon  the  inflamed  part.     Such  an  application  may,  it  is 


n  of  cold 
ase  of  its 
ed.  Ex- 
died  with 
fere  with 
ill  lessen 
aperature 
t  to  a  de- 

evapora- 
ure.     To 

or  there 
n,  and,  if 
d  I  can, 
e  a  piece 
ig  dipped 
be  neces- 
:plicit  in- 
;c.,  other- 
•al  times, 
'ater,  will 
I  a  steam- 
mav,  it  is 


TREATMENT    OF    INFLAMMATION. 


69 


true,  prove  beneficial  as  a  vapor  bath,  but  not  as  a  cold  applica- 
tion. It  is  necessary  to  have  the  cloth  thin  to  allow  free  evapo- 
ration. Just  as  soon  as  the  cotton  has  dried  or  its  temperature 
raised  to  that  of  the  body,  it  ought  at  once  to  be  reapplied.  In 
those  cases  where  the  inflammation  coexists  with  a  wound,  the  dis- 
turbance of  the  cloth  will  irritate  the  wound ;  consequently,  in- 
stead of  dipping  the  cloth  in  water  apply  the  water  with  a  sponge 
or  another  piece  of  cotton,  allowing  it  to  drip  upon  the  part.  In 
this  case,  however,  the  attention  will  have  to  be  more  diligent. 
The  vessel  of  water  must  frequently  be  renewed,  or  the  water  have 
ice  in  it. 

A  part  may  be  kept  wet  and  cold  by  irrigation,  but  this  cannot 
be  done  without  some  diflBculty ;  moreover,  the  continued  dripping 
is  likely  to  be  attended  with  discomfort  from  the  water  running 
into  the  bed  or  into  the  clothes  of  the  patient.  Another  objection 
to  irrigation  is,  that  unless  used  with  constant  caution,  there  is 
great  danger  of  reducing  the  temperature  too  much,  so  as  to  de- 
stroy vitality  of  the  tissue.  There  are  other  methods  sometimes 
recommended,  but  as  I,  in  the  main,  refer  only  to  such  as  my  own 
experience  has  proved  worthy  of  recommendation,  I  may  be  par- 
doned for  omitting  them.  There  is,  however,  one  other  method 
which  I  wish  to  dwell  upon  for  a  brief  time. 

In  the  winter  of  1863-4  I  had  the  opportunity,  when  on  a  visit 
to  the  United  States  Military  Hospitals  in  and  about  Washington, 
of  witnessing  what  was  to  me  quite  a  new  mode  of  applying  cold, 
never  having  seen  it  nor  heard  of  it  before.  It  consisted  in  the 
application  of  ice  to  inflamed  parts  arising  from  gunshot  wounds 
of  every  kind,  a  piece  of  cloth  folded  two  or  three  times  inter- 
vening. I  was  assured  that  inflammation  (and  these  wounds  are 
generally  followed  by  a  good  deal  of  inflammation)  was,  when 
taken  in  time,  to  a  great  extent  prevented,  and  when  it  had  arisen 
was  often  quickly  and  eff"ectually  subdued.  Subsequently,  during 
the  following  summer,  when,  for  a  time,  holding  an  appointment  in 
the  United  States  Medical  Service,  and  doing  duty  in  the  Lincoln 
Hospital,  Washington,  I  availed  myself  of  the  chance  of  testing 
what  I  had  felt  sure  was  a  most  excellent  practice.  In  the  vast 
majority  of  cases  which  came  under  treatment  in  that  Hospital, 
and  indeed  in  all  the  hospitals  of  Washington,  some  time  had 
elapsed  from  the  time  of  receiving  the  wound  until  the  entrance 


If 


«.ii 


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r 


70 


PRINCIPLES    OF    SURGERY. 


i 


into  the  hospital.  Much  inflammation  had  arisen,  yet  in  every  case, 
whether  the  wound  was  in  a  limb,  or  in  the  chest,  or  the  abdomen, 
or  the  head,  the  application  of  ice  in  the  manner  above  stated  had 
a  most  decisive  effect.  But  I  had  the  most  favorable  opportunity 
of  trying  its  effects  upon  a  large  number  who  had  been  recently 
wounded,  who  indeed  were  transported  to  Lincoln  Hospital  within 
twenty  hours  of  the  time  of  being  wounaed,  and  who  had  received 
no  previous  treatment  whatever.  They  belonged  to  the  cavalry 
force,  and  had  been  wounded  in  the  afternoon  while  engaged  with 
a  similar  force  of  the  enemy  at  Beverly  Ford,  and  they  reached 
the  hospital  about  four  o'clock  the  following  morning.  I  happened 
to  be  the  officer  of  the  day,  and  many  of  them  were  placed  under 
my  own  immediate  care.  Among  a  comparatively  large  number 
under  my  own  care,  and  as  well  as  of  other  surgeons,  all  of  which 
I  carefully  watched,  there  were  wounds  in  every  part  of  the  body. 
In  every  case  where  the  ice  treatment  was  pursued  the  result  was 
the  most  happy,  and,  in  some  cases,  beyond  our  most  sanguine  ex- 
pectations. 

The  principles  upon  which  this  treatment  is  based  are  most 
reasonable.  By  means  of  the  ice  the  temperature  is  constantly 
maintained  at  the  same  degree.  It  can  be  regulated  by  changing 
the  degree  of  thickness  of  the  intervening  cloth,  rather  than  by 
the  size  of  the  piece  of  ice.  Another  advantage  is,  that  the 
patient  requires  a  less  constant  attention;  and  if  depending  upon 
a  negligent  nurse  he  is  less  likely  to  suffer  therefrom,  inasmuch 
as  a  piece  of  ice  will  last  a  much  longer  time  than  a  wetting  with 
cold  water.  There  is  but  one  objection,  which  is,  that  the  meltintj 
ice  will  in  time  make  the  patient  uncomfortable.  But  this  can  be 
easily  remedied  by  putting  the  ice  in  a  bladder,  or  a  bag  made  of 
oiled  silk  or  gutta  perclia. 

Heat  is  also  a  sedative,  and  in  the  form  of  hot  fomentations  is 
very  useful.  It  lil'ewise  acts  upon  the  irritated  nerves.  The 
soothing  effect  of  tl  e  heat  is  increased  by  the  moisture.  One  is 
directly  sedative,  the  other  indirectly  so.  The  heat  immediately 
affects  the  nerves ;  the  moisture,  by  relaxing  the  distended  tissue, 
lessens  the  pressure  upon  the  disturbed  nerves,  and  thus  begets 
relief.  Thus  wo  see  that  both  heat  and  cold,  used  in  the  form 
of  water,  are  useful  remedies  in  inflammation ;  and,  indeed,  cither 
might  prove  beneficial  in  the  same  case,  poihajis  almost  equally 


4 


TREATMENT    OF    INFLAMMATION. 


71 


so.  However,  some  tissues  and  organs  seem  to  be  more  speedily 
and  surely  affected  by  the  one  than  by  the  other.  For  instance, 
in  surgical  affections  of  the  head,  cold  is  by  far  the  most  service- 
able; while  in  like  affections  of  the  abdomen,  hot  fomentations  will 
be  found  to  act  the  most  promptly ;  but  I  must  not  omit  to  men- 
tion, with  regard  to  the  latter  statement,  that  some  German  writers 
assert  that,  although  the  cold  when  applied  to  the  abdomen  is  less 
•  pleasant,  yet  its  effects  are  all  that  can  be  desired.  From  obser- 
vation and  from  personal  practice,  I  feel  bold  to  say  that  hot 
fomentations  should  always  be  used  in  inflammations  of  the  ab- 
domen. 

As  a  general  thing,  the  feelings  of  the  patient  may  be  consulted 
and  followed  as  a  guide.  In  the  eye  particularly,  it  is  found  nat 
an  inflamed  conjunctiva  will,  in  some  instances,  be  relieved  by  a 
cold  wash,  while  in  others  the  irritation  is  thereby  increased,  yet 
it  will  be  benefited  by  a  warm  collyrium. 

There  are  various  sedative  drugs  which  may  be  employed  as 
local  applications  or  administered  internally,  such  as  opium, — a 
most  valuable  one, — aconite,  belladonna,  colchicum,  &c.  Two  or 
more  sedatives  may  be  used  conjointly,  as  opium  with  warm  fo- 
mentations, in  the  form  of  poppy-head  fomentations. 

Stimulants. — Strangely  enough,  while  sedatives  are  so  very  use- 
ful in  breaking  the  chain  of  morbid  events  in  inflammation,  at 
almost  every  step  of  their  progress,  stimulants  are  also,  at  least 
in  one  stage  of  the  disease,  of  like  service.  When  it  is  remem- 
bered that  in  acute  inflammation  there  is  too  much  action too 

much  irritation — it  would  seem  that  stimulants  must  certainly  bo 
contra-indicated;  yet  experience  has  proved  their  efficiency,  while 
theory  will  be  found  to  fully  support  the  practice.  I  will  adduce 
a  few  common  instances,  in  which  stimulants  have  in  practice 
been  found  decidedly  beneficial. 

A  common  cold,  inflammation  of  the  Schneiderian  membrane, 
is  often  relieved  by  the  use  of  snuff,  which  stinnilatcs  the  tissue, 
although  already  over-congested.  Again,  if  the  "cohl"  affects 
the  mucous  membrane  of  the  bronchi,  it  may  be,  sometime 
promptly  relieved  by  a  hot,  stimulating  drink  at  bedtime.  Con- 
gcstion  of  the  liver  is  frequently  cured  by  a  calomel  pill,  which 
stimulates  that  organ.  Conjunctivitis  is  often  cured  by  a  stimu- 
lating collyrium,  and  an  inflamed  throat  by  a  capsicum  irarglo. 


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72 


PRINCIPLES    OP    SURGERY. 


[!1 


These  are  instances  of  a  similar  nature.     This  is  the  successful 
practice. 

Now,  how  may  it  be  explained  theoretically?  Fortunately, 
very  easily.  According  to  Paget,  when  a  frog's  foot  or  a  bat's 
wing  is  placed  under  the  microscope,  is  irritated  until  the  pheno- 
mena of  inflammation  begin  to  present  themselves,  and  paralysis 
of  vessels  is  almost  accomplished,  a  renewed  effort  to  contract 
may  be  provoked  by  increasing  or  varying  the  irritant,  as  if  de- 
parting life  were  brought  back  by  the  increased  irritation.  This 
renewed  or  increased  contraction  of  the  coats  causes  the  blood, 
which  was  moving  so  sluggishly,  to  pass  on  with  a  perceptible 
increase  of  velocity,  whereby  the  stagnation  is  delayed,  perhaps 
averted.  And  no  doubt  the  same  events  would  be  seen  to  trans- 
pire, could  the  tissue  in  the  human  body  be  similarly  inspected 
under  like  circumstances.  The  stagnation  of  the  blood  marks  the 
establishment  of  disease,  and  anything  which  .will  delay  it,  cannot 
but  be  regarded  as  a  remedial  measure.  Thus  we  find  that  prac- 
tice is  supported  by  theory. 

But  while  stimulants  do  undoubtedly  prove  very  often  remedial 
in  their  effects,  the  use  of  them  must  be  considered  hazardous 
unless  administered  with  great  caution.  Bearing  in  mind  the 
pathology  of  inflammation,  and  the  viodu8  operandi  of  stimulants, 
it  will  easily  be  understood  that,  if  they  fail  to  do  good,  they 
necessarily  aggravate  disease.  I  would  not,  therefore,  be  under- 
stood to  recommend  the  indiscriminate  use  of  stimulants  as  a  local 
application  in  the  treatment  of  inflammation,  nor  would  1  have 
them  placed  alongside 'of  sedatives  or  astringents,  which  I  have 
next  to  notice. 

Astringents. — The  effects  of  an  astringent  medicine  upon  the 
mucous  niombrane  of  the  mouth,  for  instance,  is  well  understood. 
There  is  a  sensation  of  puckering— of  drawing  together  of  the 
tissue.  Wlicn  applied  to  the  skin  the  effect  is  the  same,  although 
not  so  approciable.  At  all  times,  this  drawing  together  of  the 
tissues  will  necensarily  tend  to  press  out  of  the  interstices  the  fluid 
therein  contained.  In  inflammation,  when  the  coats  of  the  vessel 
are  beginning  to  succumb  to  the  pressing  blood,  an  astringent,  by 
virtue  of  external  pressure  which  it  gives  to  the  tired-out  coats, 
will  assist  to  force  onward  the  sluggish  stream  of  blood.  At  tiio 
samo  time,  any  fluid  which  may  have  transuded  into  the  tissue, 


li 


TREATMENT    OF    INFLAMMATION. 


78 


will  stand  a  chance  of  being  pressed  out  of  the  part  by  being 
brought  into  contact  with  acting  absorbents.  In  this  way,  by  the 
calibre  of  the  vessels  being  diminished,  and  the  blood  forced  away 
from  the  part,  the  equilibrium  will  often  be  restored.  No  effusion 
had  taken  place  which  cannot  be  absorbed,  and  the  disease,  which 
may  have  been  most  threatening  in  its  appearance,  is  averted,  or 
cured,  simply  by  the  application  of  an  agent  which  made  gentle 
pressure  by  its  physical  eifects  upon  the  tissue. 

Foremost  among  the  astringents  suitable  for  the  treatment  of 
inflammation,  as  well  as  among  the  sedatives,  is  cold  water.  Its 
virtue  as  a  styptic  will  be  pointed  out  in  connection  with  the  treat- 
ment of  hemorrhage.  Possibly  the  astringent  action  follows  the 
sedative ;  but  whether  this  be  so  or  not,  its  properties  as  an  as- 
tringent are  satisfactorily  established. 

Plumbi  acetas  is  a  most  valuable  medicine  of  this  kind.  The 
powder  dissolved  in  water,  in  the  form  of  Goulard's  Extract,  is  the 
way  in  which  I  generally  use  it,  and  in  good  strength.  To  it  may 
be  added  some  preparation  of  opium.  Having  used  this  almost 
exclusively  as  a  local  application  in  inflammation  for  many  years, 
I  feel  that  I  may  speak  ex  cathedra,  and  say,  that  when  diligently 
used  it  will  never  disappoint  the  surgeon,  and  that  I  know  of 
nothing  that  can  take  its  place.  I  am  aware  that  it  is  no  new 
remedy;  but  in  this  day  of  change  and  of  forsaking  of  old  reme- 
dies to  try  new  ones,  there  is  a  possibility  of  neglecting  a  useful 
thing  for  the  novelty  of  the  untried.  It  seems  to  be  somewhat 
sedative  as  well  as  astringent. 

Thus  far,  in  speaking  of  remedies,  reference  has  been  made  to 
that  stage  of  the  inflammatory  process  where  the  disease  is  not 
fully  established.  But  it  must  be  understood  that,  after  the  dis- 
ease is  in  all  respects  established,  the  same  remedial  agents  will 
continue  to  prove  useful ;  for,  although  the  district  in  Aviiich  the 
disease  has  arisen  may  have  passed  into  a  state  of  "  true  inflam- 
mation," there  will  be  in  the  parts  surrounding  it  the  same  condi- 
tion as  had  previously  cxis**^'!  ;«  tho  former  part. 

I  proceed  next  to  speak  of  cvncuants. 


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74 


PRINCIPLES    OF    SURGERY. 


CHAPTER    IX. 

Treatment  continued — Evacuants,  including  Derivatives,  Emetics,  Purgatives, 
Diuretics,  Diaphoretics— General  Bleeding — Direct  Evacuation  of  Blood — 
Cupping — Leeching — Puncturing— Counter-irritants— Kubefacients— Pres- 
sure. 

These,  for  consideration,  will  be  divided  into  local  and  general, 
or  those  which  draw  off  fluid  from  the  part  directly,  and  those 
which  accomplish  the  same  end  by  acting  upon  the  general  sys- 
tem.    The  latter  I  will  speak  of  in  the  first  place. 

Those  which  act  through  the  system  are  emetics,  pwgatwes, 
diuretics,  diaphoretics,  and  bleeding. 

With  respect  to  emetic i,  some  doubt  may  reasonably  be  enter- 
tained as  to  their  being  beneficial  in  inflammation.  When  food 
has  been  taken  into  the  stomach  and  will  not  be  digested,  or,  if 
so,  will  be  very  imperfectly  done,  and  which  will  consequently 
enter  the  system  as  a  crude  irritant  material,  and  not  as  a  nutri- 
ment, then  the  administration  of  an  emetic,  to  cause  the  stomach 
to  eject  it,  will  |  rove  highly  beneficial;  but  when  such  is  not  the 
case  (and  it  must  be  admitted  that  such  instances  are  very  rare, 
for  the  patient  does  not  become  so  suddenly  ill, — is  not  likely  to 
have  been  eating  in  large  quantities  so  recently),  then  an  emetic 
is  more  likely  to  prove  injurious  than  beneficial.  The  fruitless 
retching  and  straining  is  painful  and  exhausting,  and  will  be  fol- 
lowed by  great  reaction,  which  will  in  turn  affect  all  parts  of  the 
body.  If  the  depression  were  maintained,  benefit  would  result ; 
but  emosis  followed  by  reaction  is  only  evil,  with  the  exception 
before  stated.  When  there  is  nausea  it  may  as  a  general  thing  be 
looked  upon  as  intelligent  information  that  there  is  in  the  stomach, 
ingesta  which  the  system  refuses,  and  consequently  an  emetic  may 
be  given. 

While  the  use  of  emetics  may  be  questioned,  the  employment  of 
pvrgatit'ps  is  always  useful  in  the  treatment  of  inflammation,  unless 
the  action  of  the  bowels  will,  because  of  contiguity,  increase  the 
irritation  ;  the  disease  existing  in  the  abdominal  region.     In  most 


TREATMENT    OP    INFLAMMATION. 


76 


cases  they  afford  the  most  important  benefit,  and  cannot  be  over- 
looked. The  bowels  are  mostly  always  constipated  (vide,  general 
symptoms).  The  dry  state  of  the  mucous  membrane  of  the  intes- 
tinal canal,  the  arrest  of  secretion  by  the  liver  and  other  glands, 
causes  a  retention  of  the  faeces,  which  becoming  dry  and  hard, 
prove  a  source  of  irritation  to  the  constitution.  The  prompt  and 
complete  removal  of  this  substance  will  prove  salutary,  inasmuch 
as  the  total  amount  of  constitutional  irritation  will  thereby  be  les- 
sened. 

But  particularly  the  purgative  will  arouse  to  action  the  glands 
of  the  intestinal  track,  by  which  copious  evacuations  may  be 
secured  of  watery  material,  in  which  will  be  found  a  certain  quan- 
tity of  albumen,  by  the  means  of  which  the  richness  of  the  blood 
will  be  lessened.  The  derivative  effect  obtained  in  this  way  is 
very  considerable.  The  total  surface  of  mucous  membrane  from 
which  secretion  flows  is  said  to  be  about  1400  square  inches 
(Meckel) ;  and  if  excretion  continue  therefrom  for  any  length  of 
time  the  blood  will  be  materially  affected. 

In  addition  there  is  the  counter-irritation  and  counter-congestion, 
by  which  nature  is  diverted,  to  a  very  great  extent,  from  the  seat 
of  inflammation.  Practice  will  show  that  very  decided  and  im- 
portant relief  can  be  obtained  by  the  judicious  exhibition  of  purga- 
tives in  acute  inflammation,  with  the  exception  above  referred  to, 
when  the  inflammation  is  located  in  the  abdomen. 

Diuretics.— y^ hen  inflammatory  fever  exists,  the  kidneys  are 
unable  to  perform  their  function ;  the  increased  tone  of  the  vas- 
cular coats  affects  these  organs  in  common  with  other  parts.  The 
urine  is  therefore  scanty  and  highly  colored.  In  the  water  which 
does  transude  through  the  tubules  there  is  a  large  quantity  of 
urea.  Now,  if  the  kidneys  be  not  themHclvcs  affected,  it  is  at  least 
desirable  to  bring  about  a  more  healthy  action  of  these  excreting 
organs,  so  that  all  the  urea  will  be  eliminated ;  and  often  the  sys- 
tem or  blood  may  bo  relieved  of  a  certain  quantity  of  fluid.  More- 
over the  increased  action  of  the  kidneys  is  a  counter-irritation. 

As  it  is  not  my  object  to  dwell  upon  individual  medicines,  unless 
such  as  I  have  fully  tested,  I  will  be  pardoned  if  I  only  allude  to 
one.  All  the  preparations  of  potassa  are  valuable;  but  I  have 
found,  as  is  often  the  case,  the  most  common  to  be  the  most  use- 
ful ;  that  is,  the  nitrate.    I  do  not  know  that  my  treatment  in  this 


.  1 


F,  ■»■ 


|i     H 


'Jii  f 


76 


PRINCIPLES    OP    SURGERY. 


respect  is  very  extraordinary,  unless  in  these  respects,  that  I  trust 
to  potash  alone,  and  give  it  in  large  doses  and  every  hour,  as  long 
as  there  is  fever.  The  object  in  view  is  to  start  the  kidneys ;  but 
I  think  that  more  than  this  is  to  be  accomplished.  As  is  well 
known,  the  blood  itself  is  beneficially  affected ;  of  this,  however,  I 
shall  speak  hereafter.  I  have  noticed,  in  addition,  that  the  action 
of  the  heart  is  very  soon  diminished ;  that  increase  of  tone  in 
the  whole  vascular  system  seems  to  be  lessened ;  in  a  word,  there 
is,  in  a  comparatively  short  time,  a  great  abatement  of  the  fever. 
So  well  has  this  drug  answered  my  expectation,  that  I  now  always 
give  it  when  there  is  heat  of  skin  with  an  increased  pulse. 

Diaphoretics  are  also  a  very  important  class  of  medicines  in  the 
treatment  of  inflammation.  The  skin  is  dry  and  hot;  the  pores- 
are  closed ;  excretion  of  effete  matter,  which  normally  takes  place 
from  the  skin,  has  entirely  cet',0'1.  To  relieve  this  unnatural  con- 
dition, induced  by  the  inflammatory  action,  and  itself  an  additional 
cause  of  inflammatory  action,  diaphoresis  should,  as  speedily  as 
possible,  be  produced ;  so  that  the  material  ordinarily  eliminated 
by  the  skin  shall  no  longer  be  retained  in  the  system,  and  so  that 
the  integumentary  vessels  shall  be  relieved.  Nitrate  of  potash,  of 
which  I  have  ventured  to  speak  so  highly,  will  serve  a  good  pur- 
pose as  a  diaphoretic.  I  have,  in  cases  of  inflammation  of  im- 
portant internal  organs,  found  the  veratrum  viride  to  act  both 
upon  the  heart  and  skin.  Regarding  this  medicine,  I  shall  have 
something  to  say  hereafter  in  connection  with  a  case  of  gunshot 
wound. 

Bleeding  is  the  next  agent  to  which  I  desire  to  direct  attention. 
Concerning  this  mode  of  evacuation,  or  depletion,  a  very  great 
difference  of  opinion  may  be  said  to  exist,  and  to  have  existed  for 
some  time  past.  In  the  blood  are  the  elements  of  nutrition  ;  it  is 
the  tissues'  food.  For  the  welfare  of  the  tissues  it  is  necessary 
that  blood  should  exist  in  a  state  of  nature.  No  more  normal, 
true  blood,  is  produced  than  nature  rc(i[uires.  In  the  system  is  no 
laboratory  in  which  a  larger  quantity  than  usual  of  blood  can  be 
expeditiously  manufactured  on  demand.  On  the  contrary,  it  seerae 
to  grow,  to  be  gradually  develop«'(l.  And  more  than  thiti,  con- 
tinued development  of  blood  deprr  1/>,  not  simply  upon  the  iu, de- 
duction of  aliment,  but  especially  upon  the  blood  already  in  » x 
istence.  Speaking  somewhat  roughly,  the  young  blood  is  Hn: 
offspring  of  the  old.     If  the  old  bo  destroyed,  removed  from  the 


Nil. 


TREATMENT    OF    INFLAMMATION. 


7T 


body,  of  course  it  can  no  more  beget  offspring.  Therefore,  after 
abstraction  of  a  quantity  of  blood,  tliat  which  remains  will  be  want- 
ing in  strength  and  vitality,  and  the  tissues  depending  upon  it  will 
become  sufferers.  More  than  this,  after  inflammation,  repair  will 
have  to  be  made  in  the  part  which  had  been  affected ;  so  that,  in 
addition  to  ordinary  repair,  blood  will  be  wanted  for  this  extraor- 
dinary repair.  Now,  whatever  may  be  the  elements  of  the  blood 
required  for  each  of  these  processes,  it  matters  not  regarding  this 
question.  When  blood  is  taken  from  the  system,  in  the  main  all 
the  elements  of  the  fluid  are  common  sufferers.  Therefore  I  un- 
hesitatingly assert  that,  as  a  general  rule,  other  modes  of  treat- 
ment ought  to  be  sought.  But  many,  I  doubt  not,  are  ready  to 
say,  "  Granted,  that  abstraction  of  blood  is  followed  by  evils,  where 
is  your  substitute ;  for  the  testimony  of  hundreds  speak  in  its 
favor?"  Let  us  examine  the  matter.  Bleeding  has  been  practised 
for,  or  may  be  resorted  to  for  one  of  two  purposes,  either  to  draw 
off  blood  from  an  inflamed  region,  or  to  cause  sedation ;  that  is, 
to  take  blood  until  syncope  is  produced.  Well,  if  the  object  be 
to  draw  off  blood  from  an  affected  tissue  or  organ,  the  rational 
question  presents  itself,  cannot  this  be  done  with  equal  efficacy 
without  taking  the  precious  fluid  altogether  from  the  system  ?  In 
reply  to  this  I  would  say,  not  only  that  it  can  be  accomplished  as 
well  in  another  way,  but  even  better.  Local  abstraction  of  blood, 
while  it  directly  relieves  the  part,  does  not  to  a  material  extent 
affect  the  whole  volume  of  blood, — does  not  diminish  its  vitality; 
and  therefore  will  not  retard  the  curative  efforts  of  nature,  nor 
subsequently  affect  the  well-being  of  the  patient. 

"But  bleeding,"  say  some,  "is  often  necessary  to  produce 
speedy  sedation."  At  times,  undoubtedly,  when  an  important  in- 
ternal organ  is  involved,  the  integrity  of  that  organ,  perhaps  life 
itself,  may  depend  upon  a  quick  reduction  of  the  heart's  action. 
And  when  such  is  the  case,  when  the  surgeon  or  physician  has 
been  called  in  at  the  eleventh  hour,  and  no  medicine  can  be  found 
to  do  the  pressing  duty,  then  by  all  means  open  the  vein  of  the 
arm,  and  alloAV  the  blood  to  flow  until  syncope  ensues.  In  inflam- 
mation of  the  brain,  lungs,  liver,  &c.,  such  urgent  cases  may  occa- 
sionally be  met.  Hero  the  surgeon  has  to  exercise  a  choice.  Of 
two  evils  he  will  choose  the  least.  Doubtful  whether  he  can  com- 
mand medicines  to  control  the  heart's  action  as  speedily  as  is  ne- 


I 


ri 


M    't 


I 


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ii 


1 . 
1^1 


ii 


78 


PRINCIPLES    OF    SURGERY. 


cessary,  he  escapes  the  immediate  danger  by  incurring  the  risk  of 
one  that  -will  follow.     When  bleeding  is  practised  in  these  urgent 
cases  the  relief  experienced  is  generally  well  marked.     There  is 
not  only  sedation,  but  the  organ  is  relieved,  the  quantity  of  blood 
within  it  is  promptly  lessened ;  but,  unfortunately,  this  does  not 
continue.   The  depression  will  naturally  be  followed  by  a  reaction  ; 
the  heart,  momentarily  reduced  in  action,  will  very  soon  rise  to  its 
former  inordinate  activity  or  perhaps  to  a  greater.     The  volume 
of  blood  within  the  vascular  system  was  for  a  brief  time  reduced ; 
but  it  was  soon  restored,  not  by  true  blood  ;  but  to  supply  the  place 
of  the  vital  fluid  which  has  been  removed  there  will  be  taken  up 
from  the  tissues  such  juices  as  come  in  contact  with  the  absorbents. 
(Hence  the  sensation  of  thirst  after  bleeding.)     And  the  conse- 
quence is  that  into  the  part  inflamed  again  rushes  the  blood ;  but 
now  it  is  more  watery ;  and  truly  the  last  state  of  that  part  is 
worse  than  the  first.     From  this  consideration  we  may  learn  that, 
in  order  to  maintain  the  reduction  of  the  heart's  action,  a  second 
bleeding  may  become  necessary ;   and  such  is  the  practice  still 
adopted  by  some.     For  this  procedure  there  can  be  no  proper 
argument  advanced  and  no  excuse  given,  unless  indeed  it  be  in  the 
backwoods,  where  medicines  are  not  to  be  had,  or  when  unex- 
pectedly the  surgeon  finds  himself  destitute  of  such  medicines  as 
are  required.     As  a  general  thing,  and  I  say  it  with  due  conside- 
ration, although  a  first  bleeding  may  be  imperatively  demanded,  a 
second  one  can  never  become  necessary  if  only  proper  medicines 
are  administered  to  produce  sedation.     There  is  one  other  thing 
to  be  mentioned  in  this  connection,  namely,  that  when  the  lancet 
is  used  the  patient  ought  to  be  in  the  upright  position,  so  that  the 
desired  eff"ect  may  be  produced  with  the  least  possible  loss  of 
blood. 

Local  Bleeding. — I  have  said  that  local  bleeding  will,  in  most 
cases,  more  eff'ectually  draw  off  blood  from  a  part  than  will  general 
bleeding.  The  blood  may  be  actually  abstracted  from  the  body, 
or  it  may  be  drawn  to  a  neighboring  part,  where,  being  retained 
for  a  time,  the  affected  tissue  is  enabled  to  recover  its  tone  before 
stagn9,tion  of  blood  takes  place;  or,  if  "true  inflammation"  exist, 
to  take  on  a  physiological  action.  The  advantage  of  this  latter  is 
manifest.  One  of  the  objects  even  of  general  bleeding  is  obtained, 
drawing  away  the  blood ;  yet  that  fluid  remains  in  the  system,  and 


TREATMENT    OF    INFLAMMATION. 


79 


although  it  was  imprisoned  for  a  while,  it,  as  soon  as  released, 
starts  again  on  its  course  of  circulation.  This  treatment  is  often 
practised  in  the  form  of  dry  cupping.  By  their  application  a  quan- 
tity of  blood  may  be  collected  in  a  part  for  a  certain  length  of  time. 
We  have  here  not  simply  a  plausible  hypothesis,  but  sound  prin- 
ciples of  practice.  I  speak  from  considerable  experience,  derived 
from  hospital  practice  when  house  surgeon,  and  also  from  private 
practice ;  and  I  must  say  that  I  have  often,  in  treating  congestion 
and  actual  inflammation  of  the  lungs,  instead  of  using  the  lancet, 
a  la  mode,  covered  the  chest  with  cupping  glasses,  and  have  been 
surprised  at  the  great  and  prompt  relief  that  was  thereby  secured. 
Dry  cupping  is  equally  salutary  oftentimes  when  applied  to  the 
back  in  spinal  complaints ;  and  to  the  neck  in  inflammation  of  the 
brain,  &c.  But  I  have  referred  especially  to  the  case  of  the  lungs, 
because  in  this,  I  think,  more  than  in  any  otherj  general  bleeding 
is  occasionally  really  demanded.  The  practice  of  drawing  blood 
to  a  part,  and  retaining  it  there  for  a  time  to  relieve  inflammation, 
is  not  new,  nor  is  it  confined  to  any  country.  Some  years  ago 
an  ingenious  Frenchman  invented  a  glass  vessel  in  which  to  place 
the  leg,  and  then,  by  exhausting  the  air  in  it,  caused  blood  to 
occupy  ♦:he  leg  to  an  inordinate  extent.  This  was  done  to  evacuate 
blood  from  an  engorged  lung. 

Now  I  wish  to  repeat  that  ray  humble  opinion,  based  on  the 
varied  experience  which  I  have  had  the  opportunity  to  acquire  in 
American  and  English,  as  well  as  in  Canadian  practice,  is,  that 
bleeding  is  rarely  necessary, — that,  for  the  purpose  of  evacuating 
an  inflamed  part  of  blood,  cupping,  very  often  dry,  and  if  not  wet, 
will  be  fully  adequate  to  meet  the  requirements, — will,  indeed,  in 
that  respect,  accomplish  as  much  as  would  general  bleeding ;  and 
that,  for  the  object  of  producing  sedation,  we  have  available  other 
means,  not  objectionable,  yet  quite  as  certain,  and  almost  as  speedy. 
( Vide,  remarks  on  veratrum  viride,  &c.) 

The  terms  wet  cupping  and  dry  cupping  have  been  used ;  these 
scarcely  need  explanation,  more  than  has  been  given.  In  ivet 
cupping  the  scarificator  is  used,  by  which  several  incisions  are 
simultaneously  made  through  the  integument ;  and  then  the  cup 
of  glass,  having  been  exhausted  of  air,  is  applied  to  the  part; 
whereupon  the  blood  is  forced  by  atmospheric  pressure  into  it, 
from  the  numerous  small  vessels  that  have  been  divided.     Drv 


■4  • 


tl 


i     '1 


1" 


80 


PRINCIPLES    OF    SURGERY. 


'l!i 


m  J 


cupping  consists  in  using  the  cups  alone,  by  which  the  blood  is 
drawn  to  the  skin  and  subcutaneous  tissue,  there  to  be  retained  for 
a  time. 

Direct  evacuation  of  blood  from  a  part  may  be _  performed  by 
three  methods, — by  cupping,  ur  by  leeching,  or  by  punctures. 
Cups  or  leeches  must  never  be  applied  directly  to  the  inflamed 
tissue,  as  it  would  be  an  additional  source  of  irritation ;  and  the 
bite  of  the  leech  is  particularly  so,  because  of  its  poisonous  na- 
ture ;  the  )-esult  of  which  would  be  that,  althouo'h  the  congested 
part  might  momentarily  be  relieved,  yet  the  blood  would  thereafter 
be  more  freely  drawn  to  the  part.  The  blood,  therefore,  must  be 
abstracted  from  tissue  in  the  immediate  neighborhood  of  that  in- 
flamed. The  current  of  blood  pouring  to  the  part  will  then  be 
turned  aside,  and  a  diversion  created  which  will  have  the  effect  of 
relieving  the  vessels  which  had  wellnigh  become  paralyzed. 

The  practising  surgeon  ought  to  be  well  acquainted  with  the 
details  of  practice.  In  cupping  he  should  see  that  no  unnecessary 
pain  is  inflicted, — and  careless  cupping  may  cause  a  good  deal  that 
ought  to  be  avoided, — that  the  clothes  are  not  soiled  by  blood, 
and  at  the  same  time  that  it  is  done  in  the  most  expeditious  man- 
ner. In  country  practice  it  will  often  happen  that  this  operation 
requires  to  be  performed  when  the  cupping  glasses  and  scai'ificator 
are  not  at  hand.  But,  with  regard  to  the  glasses,  a  ready  and 
serviceable  substitute  will  be  found  in  the  wineglass  or  tumbler ; 
then  a  few  drops  of  alcohol  dropped  into  it  and  ignited  by  a  little 
slip  of  paper,  will  exhaust  the  air.  And  in  the  absence  of  the 
scarificator,  should  the  patient  stand  in  urgent  need  of  wet  cup- 
ping, the  part,  after  having  had  the  cup  applied  to  it,  may  be  punc- 
tured quickly  in  a  few  places,  as  a  substitute  for  scarifying.  Cur 
ping  cannot  be  too  highly  recommended,  especially  m  cases  wh'  re 
an  internal  organ  is  congested  or  inflamed. 

Leeches. — In  cases  where  the  surface  is  so  uneven  that  a  cup 
cannot  be  used,  leeches  will,  if  obtainable,  take  its  place.  Again, 
sometimes  the  part  is  so  painful  or  sensitive  that  cupping  cannot 
be  tolerated  by  the  patient ;  in  which  case  also  leeches  must  be 
substituted.  There  are  also  many  parts  of  the  body  to  which  cups 
could  not  be  applied  where  leeches  will  be  found  to  answer  instead. 
The  fact  that  the  leech-bite  is  somewhat  poisonous  is  to  be  remem- 
bered.    Sometimes,  if  applied  to  the  afi'ected  part,  it  increases  the 


II 


TREATMENT    OP    INFLAMMATION. 


81 


inflammation  very  much;  and  often,  when  applied  to  tissue  that 
is  lax,  as  about  the  eyelid,  it  will  give  rise  to  a  good  deal  of  serous 
infiltration. 

Puncturing.— Incisions  made  in  the  tissue  inflamed  will  often 
give  very  great  and  prompt  relief  to  the  patient,  prevent  extension 
of  the  disease,  and  perhaps  destruction  of  the  tissue.  These  cuts 
should  be  short  and  quickly  made.  The  patient  will  be  likely  to 
object  to  this  practice  because  of  the  pain  ;  and,  if  the  part  is  com- 
monly  exposed,  for  fear  of  a  scar  resulting.  When  the  incision  is 
first  made,  as  the  tissue  is  more  or  less  distended,  swollen,  there 
will  be  gaping,  perhaps,  to  a  considerable  extent ;  but  generally, 
after  the  swelling  subsides,  in  consequence  of  the  escape  of  blood,' 
the  cuts  do  not  appear  so  large ;  while,  should  no  incision  be  made 
until  pus  form,  the  risk  of  a  resulting  scar  will  be  far  greater. 
The  bleeding  can  be  promoted  by  fomenting  the  part;  at  the  same 
time  the  part  is  thereby  soothed. 

There  are  other  methods  by  which  blood  may  be  drawn  from  a 
part,  or  rather  turned  into  another  place,  as  by  counter-irritants. 

In  not  a  few  cases  of  inflammation  a  mustard  poultice  will  give 
to  the  patient,  seriously  ill,  with  symptoms  of  no  little  disease,  the 
most  prompt  and  efficient  relief.  This  I  have  seen  more  especially 
follow  its  use  when  an  internal  organ  was  involved.  It  is  not  a 
little  strange  that  a  remedy  so  efficacious  should,  even  among  in- 
telligent practitioners,  be  so  rarely  used.  I  have  seen  it  used  in 
many  hundred  cases  as  a  counter-irritant,  and  always  with  benefit, 
never  with  harmful  efi*ects.  The  modus  operandi  is  very  simple! 
The  mustard  acts  as  an  irritant  to  the  skin,  and  engages  the  nerves, 
by  which  a  diversion  is  created.  I  cannot  find  a  more  convenient 
and  expressive  term.  The  irritation  is  followed  by  a  flow  of  blood 
to  the  part  where  the  mustard  bas  been  applied.  Mustard  and 
other  like  substances  are  partic  arly  useful  in  the  first  stage  of 
the  inflammatory  process;  but  they  are  also  beneficial  at  almost 
every  subsequent  period.  The  length  of  time  necessary  to  produce 
the  required  irritation  and  congestion  will  depend  upon  the  age, 
the  sex,  the  sensitiveness  of  the  part,  as  well  as  the  strength  of 
the  mustard.  From  ten  to  thirty  or  forty  minutes  will,  as  a  gene- 
ral thing,  be  sufficiently  long.  The  directions  I  am  in  the  habit 
of  giving  are  to  apply  it  immediately  to  the  skin,  and  leave  it  there 
until  the  part  is  well  reddened. 


i  s 


I  *  i 


mi 


■4 


;-iJ        I-   ■    'av'.! 


4 


82 


PRINCIPLES    OF    SURGERY. 


Mustard  ia  a  rubefacient ;  and  when  it  cannot  be  had,  although 
that  is  not  often  the  case,  other  means  may  be  adopted  to  make 
the  skin  red.  Brisk  rubbing  will  do  it ;  and  I  have  seen  promi- 
nent symptoms  of  congestion  of  the  lungs  dissipated  by  this  pro- 
cess. Fomentations  of  very  warm  water,  reaction  after  cold  ap- 
plications, or  a  hot  linseed  poultice,  will  redden  the  skin,  perhaps 
at  the  same  time  affording  relief  by  soothing  the  nerves  and  relax- 
ing the  tissue. 

Pressure  made  against  the  part,  so  as  to  force  away  the  fluid, 
and  prevent  its  entrance,  and  thereby  to  sustain  the  distended  ves- 
sels, is  another  excellent  remedial  measure.  The  importance  of 
such  pressure  has  been  explained  in  connection  with  astringents. 
Pressure  is,  indeed,  another  similar  mode  of  using  mechanical  force. 
It  is  commonly  effected  by  a  bandage.  But,  as  the  pressure  re- 
quires to  be  uniform,  it  is  obvious  that  the  bandage  should  be  accu- 
rately adjusted  ;  otherwise  it  will  not  only  fail  to  do  good,  but  will 
be  the  source  of  very  great  evil.  In  case  the  bandage  is  not  made 
to  fit  perfectly  the  varying  form  of  the  limb,  the  pressure  will  be 
greater  in  some  places  than  in  others,  and  the  parts  not  duly 
pressed  upon  will  become  the  seat  of  inflammation,  at  least  of  swell- 
ing. Should,  for  instance,  a  bandage  be  applied  more  tightly  at 
the  ankle  than  around  the  foot,  the  return  of  venous  blood  will  be 
arrested  in  the  superficial  veins,  so  that  it  will  naturally  collect  in 
the  foot,  and  aggravate  or  even  cause  inflammatory  action.  As 
the  art  of  bandaging  can  only  be  acquired  by  considerable  prac- 
tice, I  would  recommend  students  to  gain  some  knowledge  of  it 
by  practising  on  one  another.  I  will  risk  being  thought  too 
lengthy  on  this  subject,  that  there  may  be  no  failure  to  bring 
before  the  reader  the  important  bearings  of  this  remedial  measure. 
This  is  done  because  many  instances  have  come  under  my  notice 
where  the  obvious,  and,  one  would  think,  simple  principles  of  this 
treatment  were  grossly  violated  (and  that  by  surgeons  of  experi- 
ence and  deserved  reputation),  and  to  such  an  extent  as  to  jeopar- 
dize a  limb.  I  have,  in  not  a  few  cases,  when  called  upon  to  give 
advice,  in  consultation  upon  inflammatory  affections  of  some  one 
of  the  several  limbs  of  the  body,  proposed  the  use  of  judicious 
bandaging,  which  proposition  met  with  the  declaration  that  a 
bandage  had  been  tried,  but  could  not  be  tolerated  ;  but,  on  making 
inquiries,  have  ascertained  that  the  bandage  had  not  been  properly 


TREATMENT    OF    INFLAMMATION. 


83 


adjusted.  That  such  had  been  the  ease  was  substantiated  by  the 
fact,  that  subsequent  bandaging  was  attended  with  the  greatest 
benefit.  Many  surgeons,  having  seen  the  evils  of  uneven,  imper- 
feet  bandaging,  cease  to  use  it  altogether.  To  this  subject  refer- 
ence will  be  made  in  connection  with  the  treatment  of  fractures. 
It  will  suffice  here  to  add,  that  the  bandage  should  always  be  made 
a  degree  tighter  at  the  extremity  of  the  limb,  where  it  should 
always  be  commenced ;  and,  as  the  hand  carries  the  bandage  up 
the  limb,  the  roller  will  be  less  firmly  applied. 

But  pressure  may  be  effected  by  other  means  than  bandaging. 
Astringents  are  useful  as  such :  the  tincture  of  iron  I  have  found 
particularly  so  in  those  cases  where  the  congestion  i,  somewhat 
asthenic  ;  but  not  sufficiently  so  to  demand  the  use  of  iodine.    Now 
there  are  parts  of  the  body  to  which  a  bandage  to  make  pressure 
cannot  be  used ;  as  an  inflamed  breast.  In  such  cases  I  can  recom- 
mend, as  an  efficient  agent,  the  collodion.     By  means  of  it  uni- 
form and  active  pressure  may  be  exertedupon  as  much  of  the  part 
as  is  requisite.     For  a  knowledge  of  the  value  of  this  agent  in 
the  treatment  of  acute  inflammation  of  the  mamma,  I  am  indebted 
to  Dr.  Cook,  of  Canada  West.     Upon  this  subject  Dr.  Cook  fur- 
nished an  interesting  and  instructive  paper,  to  be  read  before  the 
Medico-Physical  Society  of  Victoria  College,-2.a  society  which,  I 
would  say,  "in  memoriam,"  that,  although  short-lived,  conferred 
a  lasting  benefit  upon  every  member  who  attended  its  meetings. 
In  his  paper  were  detailed  several  cases  in  which  inflammation  of 
the  mammae  had  by  him  been  successfully  treated  by  collodion. 
Dr.  Cook  would  not  undertake  to  explain  its  modus  operandi. 
After  reading  the  luminous  lectures  of  Hilton  upon  the  subject 
of  "rest,"  the  necessity  of  such,  I  found  no  difficulty  in  attribu- 
ting the  usefulness  of  collodion  in  part  to  the  pressure  which  it 
makes  upon  the  tissue  after  the  ether  has  evaporated ;  and,  in 
part,  to  the  rest  which  is  thus  secured  to  the  part,  the  coat  of  col- 
lodion effectually  preventing  any  motion  in  the  inflamed  structure. 
Thus  far,  in  considering  the  treatment  of  inflammation,  I  have 
spoken  more  especially  of  local  treatment;  although  much  has 
been  said  relating  to  constitutional  remedies ;  particularly  in  speak- 
ing of  evacuants,  we  have  seen  that  purgatives,  diaphoretics,  and 
diuretics,  by  opening  the  pores  of  the  mucous  membrane  of  the 


^:    1 


it 


i  I 
I 

,+  ■ 


84 


PRINCIPLES    OF    SURGERY. 


intestinal  canal,  the  skin,  and  by  causing  secretion  in  the  kidneys, 
give  relief  to  the  inflamed  part,  reduce  the  heat  of  the  body,  and 
thereby  obtain  relief  for  the  constitution  generally. 


;i  * 


Ih 


i 


CHAPTER    X. 

Constitutional  Treatment— Special  Medicines— Antimony— Mercury— Opiates 
— Veratrum  Viride — Aconite — Nitrate  of  Silver — Potash. 

In  treating  the  constitution  specially,  our  attention  may  have 
to  be,  in  the  ^rst  place,  given  to  some  peculiar  constitutional 
fault,  which  had  been  a  predisposing  cause  of  the  disease.  It  may 
be  necessary  to  take  steps  to  effect  the  removal  of  this  evil  at 
once,  at  least  to  place  it  in  subjection,  until  the  local  disease  is 
conquered.  Subsequently,  or  perhaps  at  first,  the  treatment  will 
be  directed  to  the  efi'ects  of  the  local  disease  upon  the  constitu- 
tion— that  is,  the  inflammatory  fever,  with  all  its  concomitants. 
In  many  cases,  however,  the  course  pursued  by  the  surgeon  will 
have  to  be  rt  /ersed :  the  inflammatory  fever  will  need  to  be  sub- 
dued, and  thereafter  any  previously  existing  evil  attended  to. 

It  would  be  beyond  the  province  of  this  work  to  even  refer  to 
the  treatment  of  the  various  evils  which  constitute  the  predisposing 
causes  of  inflammation.  Some  of  them,  however,  will  be  con- 
sidered in  connection  with  special  forms  of  inflammation. 

Of  the  treatment  of  inflammatory  fever  we  have  already  learned 
80  much  that,  in  giving  it  a  special  consideration,  not  a  great  deal 
has  to  be  said.  I  may  here  repeat  that  at  first  an  active  purgative 
should  be  administered,  to  start  into  action  the  sluggish  or  dor- 
mant intestinal  canal ;  after  which,  diaphoretics  and  diuretics, 
alone  or  combined  with  sedatives,  will  be  given.  And  in  the  mean 
time,  mental  and  pliysical  rest  should  be  observed. 

Individually  Important  Druys. — So  far,  classes  of  remedies  have 
mainly  been  referred  to ;  but  there  are  certain  ih  ..vidual  medi- 
cines, in  some  respects  specifics,  which,  because  of  their  frequent 
use  and  deserved  standing,  demand  especial  notice.  The  ^rst  of 
these,  whicu  I  now  proceed  to  notice,  is 


CONSTITUTIONAL    TREATMENT. 


85 


Antimony. — It  is  a  medicine  of  great  value,  and  as  such  has 
been  regarded  for  many  years.  As  an  antiphlogistic  it  is  adminis- 
tered to  produce,  in  the  first  place,  seciation.  When  given  in  cer- 
tain doses  it  causes  nausea,  the  effects  of  which  are  reduction  of 
the  heart's  action,  and  a  sensible  relief  to  the  whole  vascular  sys- 
tem, the  tone  of  which  had  been  so  much  increased.  Vomiting  as 
a  general  thing,  it  will  be  remembered,  is  to  be  avoided  ;  the  object 
is  to  produce  that  extreme  nausea  which  precedes  vomitin<».  To 
do  this,  and  avoid  the  vomiting,  the  drug  must  be  given  in  small 
and  frequently  repeated  doses.  The  quantity  will  have  to  be  very 
gradually  increased,  as  the  system  acquires  a  tolerance,  else  the 
effect  will  not  be  maintained.  Antimony  not  only  acts  as  a  seda- 
tive but  also  as  a  diaphoretic,  a  diuretic,  and,  in  some  instances, 
upon  the  bowels,  causing  purgation. 

•Mercury  is  the  next  medicine  deserving  of  special  notice.  It 
is  a  drug  not  so  generally  in  use  at  the  present  time  as  it  was 
formerly.  It  has  been  very  extensively  used,  and  very  muc' 
abused.  Like  a  great  many  other  really  useful  medicines  it  be- 
came a  "cure-dl,"  and  was  ruthlessly  given  when  not  required, 
and  exhibited  in  larger  doses  than  was  necessary.  Unfortunately 
it  is  not  a  harmless  medicine ;  and  its  injudicious,  its  empiric  use, 
has  probably  done  more  harm  than  is  counterbalanced  by  the  good 
it  has  ever  effected.  It  is,  therefore,  a  cause  of  thankfulness  that 
its  popularity  has  so  much  decreased.  The  conviction  that  it  led 
so  often  to  evil  effects,  caused  the  Surgeon-General  of  the  United 
States  Army  to  i  nsue  an  order,  that  thereafter  no  medical  officer 
should  employ  it. 

There  are  two  views  now  held,  I  believe,  as  to  the  manner  in 
which  mercury  acts  upon  the  system  as  a  remedy  for  inflamma- 
tion, one  of  which  is,  that  it  stimulates  the  absorbents  into  a 
more  healthy  action.  "  Stimulating  the  absorbents"  is  a  common 
and  a  convenient  expression  ;  but  what  docs  it  signify  ?  The  ab- 
sorbents cannot  reach  for  material  to  tnke  up, — cannot  draw  to 
themselves  a  fluid  which  is  not  in  contact  with  them.  The  mate- 
rial must  bo  brought  in  immediate  contact  with  the  coats  of  the 
absorbent  veaaela  by  some  other  process.  (Williams.)  Again,  if 
fluid  be  in  contact  with  them,  and  if  the  disease  do  not  incapaci- 
tate them,  they  will  readily  dischnrgo  their  duty.  But  while  there 
is  inflammatory  action,  we  have  seen  that  tranhudation  through  the 


U'l 


« 


-,ii 


It 


M 


'I 


86 


PRINCIPLES    OF    SUEGERY. 


'3!  S 
'I!'    ' 
15 


) 


uu 


f : ':  s 


i    'i 


11  K 


s' 


'i 


coats  of  vessels  is,  to  a  great  extent,  arrested ;  there  is  too  much 
tone.  Now,  if  mercury  acts  as  a  stimulant,  this  tone  would  be 
further  increased.  The  inference  is,  that  if  mercury  stimulates 
the  absorbents,  its  use  is  contra-indicated,  so  long  as  there  is  active 
inflammation,  at  least;  and  it  remains  to  be  shown  that  the  ab- 
sorbent vessels  require  any  stimulation  after  inflammation  has 
subsided, — that  is,  in  acute,  healthy  inflammation.  When  the 
disease  is  more  chronic,  and  a  want  of  tone  is  manifested  in  the 
absorbents,  then  a  stimulant  is  undoubtedly  indicated.  I  would 
not,  then,  recommend  mercury  as  a  stimulant  to  the  absorbents, 
because  those  vessels  are  too  much  irritated  already.  And  in  the 
treatment  of  eff'usion,  due  to  a  more  chronic  action,  I  think  other 
remedies  can  be  found  to  do  equally  well,  and  which  are  incapable 
of  producing  that  mischief  which  mercury  may  lead  to. 

But  I  venture  to  state  my  belief  that  mercury  never  does  act  as 
a  stimulant  to  the  absorbents.  In  those  cases  where  its  adminis- 
tration is  followed  by  increased  absorption,  is  it  not  due  to  the 
effects  which  the  drug  has  had  upon  the  fibrin  of  the  blood,  or  the 
inflammatory  lymph.  And  this  is  the  second  view  of  the  two,  above 
stated. 

It  is  conceded,  by  all  observers,  that  mercury  will  retain  the 
fibrin  in  solution — that  it  prevents  coagulation ;  and  often,  after 
coagulation  has  taken  place,  it  will  liquefy  it  again.  Now,  when 
it  is  remembered  that  such  a  state  of  fluidity  is  conducive  to  speedy 
recovery  after  the  inflammation  has  subsided,  it  will  be  admitted 
that  mercury,  to  act  thus  upon  the  fibrin,  is  a  valuable  medicine. 
But  it  must  not  be  forgotten  that  it  may  injuriously  affect  the 
constitution,  and  that  for  life.  Such  being  the  case,  it  is  well  to 
inquire  if  some  substitute  cannot  be  provided, — a  substitute  which, 
while  it  will  accorapliHh  as  much,  i.  c,  will  bave  the  same  effect 
upon  the  fibrin,  cannot,  under  any  circumstances,  lead  to  the  aame 
disastrous  results  constitutionally.  It  is  now  well  known  that 
certain  salts,  as  the  preparations  of  potash,  will  keep  the  fibrin 
in  a  liquid  state  quite  a8  well  ns  mercury.  I  will  only  add  that  I 
have  tested  the  virtue  of  potassa,  and  can  recommend  it. 

Opidtca. — Opium  and  similar  medicines  are  most  valuable  reme- 
dies in  the  treatment  of  inflammation.  They  may  bo  applied 
directly  to  the  affected  part,  either  alone  or  in  conjunction  with 
some  other  medicine,  as  an  astringent;  or  they  may  bo  adminis- 


CONSTITUTIONAL    TREATMENT. 


87 


i 


tered  internally.  Opium  is  particularly  useful  in  inflammation  of 
the  abdominal  region,  as  before  remarked.  This  can  readily  be 
understood.  It  is  the  function  of  the  intestinal  canal  to  so  move, 
as  to  pass  the  contents  along ;  there  is  almost  incessant  vermicular 
action ;  and  in  its  various  convolutions  it  comes  in  contact  with 
every  part  of  the  abdominal  parietes  and  the  several  viscera.  The 
intestines  are  suspended  in  and  confined  by  a  membrane  pecu- 
liarly susceptible  and  sympathetic.  In  all  cases  of  inflammation, 
rest  is  the  first  and  important  desideratum,  in  order  to  establish  a 
sure  hope  of  cure.  Now,  opium,  when  given,  acts  directly  upon 
the  intestinal  canal  and  the  glands,  and  soothes  the  muscular  fibres 
to  rest ;  it  arrests  those  secretions  which  will  stimulate  the  intes- 
tines to  action.  The  use  of  opium  is  rarely  contra-indicated,  unless 
there  be  severe  head  symptoms ;  and,  in  all  forms  of  inflammation, 
it  will  be  found  to  have  a  happy  eff'ect  upon  the  constitution  gene- 
rally. The  dose  will,  of  course,  vary  according  to  the  intensity  of 
the  pain  and  the  age  of  the  patient.  In  abdominal  inflammation 
a  full  dose  should  be  given.  Where  there  is  apprehension  tliat  the 
system  will  not  bear  it,  because  of  some  idiosyncrasy,  small  doses, 
often  repeated,  must  be  the  practice. 

Vemtnun  ViriJc  is  a  medicine  which  docs  not  enjoy  the  long- 
established  reputation  which  belongs  to  antimony,  but  it  success- 
fully rivals  that  drug  as  a  powerful  antiphlogistic.  It  is  a  potent 
agent ;  yet  in  the  hands  of  the  cautious  surgeon  it  can»«be  safely 
exhibited,  and,  according  to  my  own  experience,  with  the  most 
satisfactory  result.  Its  action  upon  the  heart  is  promptly  and 
powerfully  sedative.  It  also  acts  as  a  diaphoretic,  causing,  in  a 
very  short  time,  the  skin  to  become  cool  and  moist.  I  have  found 
it  particularly  useful  in  inflammation  of  the  lungs.  Two  cases  of 
such,  which  were  also  most  interesting  in  a  surgical  point  of  view, 
I  will  particularly  refer  to.  These  were  cases  under  my  imme- 
diate caro  in  Lincoln  Hospital  at  Washington.  Both  camo  in  at 
the  same  time  direct  from  the  battle-field.  The  first  one  which 
engaged  my  attention  was  unable  to  lie  down,  but  had  to  sit  leaning 
forward  considerably.  Uis  efl"orts  to  l)reatho  were  most  urgent, 
lie  could  barely  tell  me  that  ho  was  wounded  in  tlie  che8t---thnt 
the  ball  had  passed  through  his  body.  I  liastily  looked  at  the 
wound  in  front,  which  was  the  place  of  entrance ;  it  was  between 
the  fifth  and  si.xth  ribs,  on  the  right  side  of,  and  very  near  *<•>  th 


I'l 


H;  I  k^ 


88 


PRINCIPLES    OP    SURaBRY. 


I 


^"  m 


sternum.  I  not  only  considered  his  case  hopeless,  but  thought  he 
could  not  live  an  hour.  I  ordered  him  a  draught  of  compound 
spirits  of  ether,  which  was  shortly  repeated.  In  half  an  hour  he 
went  to  sleep,  his  head  resting  forward  on  a  chair,  made  somewhat 
comfortable  for  the  head.  He  slept  for  two  hours  or  more.  During 
the  sleep  and  on  waking  he  could  breathe  a  little  more  easily.  I 
examined  the  wound  posteriorly,  and  found  that  the  ball  had  passed 
almost  directly  backwards  and  had  made  its  escape.  It  was  now 
some  thirty  hours  since  the  reception  of  the  wound.  The  action 
of  the  heart  was  labored  and  there  was  some  fever ;  the  skin  was 
hot  and  dry.  I  put  him  on  veratrum  viride ;  to  be  given  often, 
in  small,  drop  doses.  I  had  every  reason  to  believe,  from  the 
symptoms,  which  I  cannot  here  fully  describe,  that  the  ball  had 
passed  through  the  lung.  It  was  several  days  before  the  patient 
could  lie  down.  Symptoms  of  pneumonia  presented  themselves, 
but  were  kept  under  control,  and  finally  the  patient  became  con- 
valescent. 

The  other  patient  was  also  wounded  with  a  ball,  which  had 
struck  the  right  clavicle  at  about  its  middle,  and,  shattering  the 
bono,  had  buried  itself  in  the  part.  In  this  case,  also,  there  was 
well-marked  signs  of  the  lung  being  wounded.  At  first  the  dis- 
tress was  not  great,  the  dyspnoea  but  little ;  in  two  days,  however, 
it  was  very  great.  He  was  ordered  the  veratrum  viride  every 
three  hours.  I  found  it  unnecessary  to  give  anything  else.  In 
a  few  days  the  symptoms  of  inflammation  subsided.  Because  of 
the  important  structures  immediately  beneath  the  clavicle,  the 
ball  was  but  slightly  searched  for.  When  the  patient  passed  from 
under  my  care  his  condition  was  most  promising.  The  wound 
remained  open,  from  which  was  a  little  purulent  dischr.v^e,  which 
might  have  been  due  to  the  necrosed  state  of  a  part  of  the  clavicle. 
Now,  both  of  these  men  were  young  and  full  of  healthy  blood,  but 
neither  general  nor  local  bleeding  was  deemed  necessary.  The 
inflammation  was  successfully  treated  soleli/  by  the  veratrum 
viride. 

Aconite  is  an  antiphlogistic,  highly  recommended  ;  but,  as  I  have 
not  had  occasion  to  use  it,  1  cannot  speak  from  personal  e.xpcri- 
ence. 

Nitrate  of  stiver  is  the  only  other  medicine  to  which  I  shall  espo- 
oially  direct  attention.     There  are  others,  certainly,  of  no  mean 


CONSTITUTIONAL    TREATMENT. 


89 


value ;  but  many  or  most  have  been  referred  to  in  connection  with 
the  several  classes  of  remedies,  and  of  these  I  would  particularly 
specify  sugar  of  lead  and  nitrato  of  potash. 

Nitrate  of  silver  is  used  as  a  local  remedy,  and  as  such  is  often 
valuable,  especially  in  limited  inflammation  of  the  skin  or  mucous 
membrane.  It  must  be  used  in  solution,  and  of  not  too  great  a 
strength.  When  thus  applied  it  seems  to  amalgamate  with  the 
superficial  part  of  the  skin,  by  which  a  coating  is  formed ;  thus  it 
seems  to  dry  up  the  tissue  with  which  it  comes  in  contact.  The 
covering  thus  formed  seems  to  protect  the  irritated  nerves  from 
the  air  and  other  irritating  agents.  Not  unlikely  the  periphery, 
which  was  principally  engaged,  is  actually  destroyed  by  the 
caustic  effects  of  the  silver.  Even  when  the  inflammation  is  sub- 
cutaneous, the  solution,  often  by  acting  upon  the  nerves  through 
reflex  action,  gives  a  degree  of  relief;  that  is  to  say,  by  soothing 
the  cutaneous  nerves,  other  nerves  in  the  same  district  are  sym- 
pathetically soothed. 

In  cases  where  some  animal  poison,  as  that  of  gonorrhoea,  has 
been  deposited  upon  a  part,  and  is  there  acting  as  a  cause  of,  and 
is  gradually  begetting  inflammatory  action,  the  process  of  incuba- 
tion may  be  arrested  by  the  application  of  the  silver,  which  will 
destroy,  dry  up  the  outside  tissue,  and  at  the  same  time  destroy 
the  poison.     To  secure  this  happy  effect  the  application  must  be 
made  before  the  inflammatory  action  is  established.    Subsequently, 
when  the  active  symptoms  have  subsided  or  disappeared,  and  there 
remains  a  chronic  discharge,  a  gleet,  the  solution  may  again  be 
called  in  requisition.     Here  again  the  beneficial  effect  is  attribu- 
table to  the  protection  given  by  the  coating  to  the  nerves  in  a 
morbid  condition.    The  function  of  the  membrane  has  >     n  changed 
by  tiie  gonorrhoea,  and,  although  the  cause  of  the  inflammation 
may  long  since  have  passed  away  in  the  discharge,  the  membrane 
remains  in  a  morbid  state  in  consequence  of  the  periodical  dis- 
charge  of  the  urine  from  the  bladder.  bM  so  the  <  •scharge  con- 
tinues.    Jut  the  silver,  in  the  way  dcFcni.ed,  forms  a  covering  to 
the  surface,  and  the  urine  tlu-reaP-v  r.  a^es  to  irritate  it,  physio- 
logical rest  is  obtained,  and  recovery  soon  follows. 

I  will  conclude  this  branch  jf  the  subject  by  repeating,  that  the 
treatment  of  the  inflammatory  process  will  always  be  modified  by 
the  circumstances  of  the  case.     The  surgeon  will  not  lose  sight  of 


I 


if,:' 
I 

i 


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% 


f!P 


;*f1i 

ri 


Hi! 


90 


PRINCIPLES    OF    SURGERY. 


the  various  surroundings  of  his  patient ;  the  causes,  local  and 
general,  which  may  continue  to  operate.  He  will  not  fail  to  con- 
sider his  age,  position,  and  particularly  the  nursing  which  he  will 
receive ;  for,  the  more  intelligent  the  nurse,  the  less  will  the  sur- 
geon have  to  do.  He  ought  to  forewarn  the  nurse  of  any  probable 
or  possible  evil  which  may  at  any  time  arise  to  complicate  the 
case,  and  render  a  more  vigorous  treatment  necessary. 


CHAPTER    XI. 


f'  ! 


Ml  i 


I     I" 


Pi 


Treatment  of  the  Products  of  Inflammation — Of  Serum — Liquor  Sangi\ini9 — 
False  Hypertrophy — Induration — Atrophy — Degenerated  Lymph  —  Pus — 

-Mucus— Blood. 


Abscess — Pointing  of  Abscess — Ditfused  Pus- 


Thus  far  I  have  considered  the  treatment  of  the  inflammatory 
action,  have  described  the  classes  of  remedies  suitable  to  each 
stage  of  the  process,  and  dwelt  upon  some  of  the  more  important 
medical  agents  with  which  the  practising  surgeon  will  deul.  I 
now  come  to  speak  of  such  treatment  as  seems  most  suitable  to 
each  product  of  the  disease.  The  products  of  inflammation  are, 
it  will  be  remembered,  serum  ;  li(iuor  sanguinis,  composed  of  serum 
and  of  lymph;  blood;  altered  mucus. 

Treatment  of  Serum. — As  a  general  thing,  this  product  of  in- 
flammation will  be  easily  removed  by  nature  if  the  infliimmation 
have  ceased.  Familiar  instances  are  known  where  it  has  been 
accomplished  after  plcuritis  ;  even  large  quantities  have  been  rap- 
idly and  completely  absorbed  after  the  disease  has  been  arrested. 
So  that  in  healthy  inflammation,  where  serum  is  the  only  product, 
the  surgeon  need  give  no  special  attention  to  it. 

Liquor  Sanguinis  is  also  often  eff'ectually  removed  by  the  un- 
aided powers  of  nature.  As  long  as  it  remains  fluid  this  may  be 
accomplished ;  and  we  have  learned,  that  in  inflammation,  the  in- 
creased vitality  of  tbe  fibrin  serves  to  retain  the  compound  for  an 
increased  time  in  a  state  of  fluidity. 

The  separation  of  the  serum  and  the  lymph  is  followed  gene- 
rally by  the  absorption  of  the  former,  and  an  attempt  to  organize 
on  the  part  of  the  latter. 


TREATMENT  OP  THE  PRODUCTS  OF  INFLAMMATION.   91 

Speaking,  generally,  the  lymph  may  coagulate  or  degenerate 
into  pus.  In  either  case  removal  by  absorption  becomes  slow,  or 
even  impossible,  unless  art  be  employed  to  assist  nature.  The 
surgeon,  then,  will  endeavor  to  promote  absorption,  and  aim  to 
retain  the  lymph  in  solution ;  or,  if  it  have  solidified,  to  bring  it 
back  into  the  same  state,  so  that  absorption  may  be  possible. 

We  have  seen  that  mercury  enjoys  the  reputation  of  being  a 
stimulant  to  the  absorbents  (this,  however,  is  questionable),  and 
of  being  competent  to  prevent  coagulation.     Further,  it  is  able  to 
produce  liquefaction  after  solidification  has  taken  place.    Mercury, 
for  these  purposes,  has  been  and  continues  to  be  frequently  used. 
But  we  have  also  learned  that  the  use  of  mercury  may  be  attended 
with  or  followed  by  very  great  constitutional  evils ;  therefore,  if 
any  other  medicine  will  accomplish  as  much,  or  nearly  as  much,  it 
by  all  means  ought  to  be  employed  instead.    I  repeat  these  state- 
ments here  because  of  their  great  importance,  as  well  as  to  bring 
out  the  importance  of  the  fact  that  the  lymph  often  remains  fluid 
for  some  time,  and  that  a  medicine  so  heroic  and  dangerous  as 
mercury  ought  not,  as  a  general  rule,  to  be  administered  to  pre- 
vent coar'ulation  from  taking  place.     At  least  before  employing 
it,  be  convinced  that  it,  or  some  such  agent,  is  demanded.     Nevei- 
give  it  blindly ;  never  run  in  the  grooves  of  routine.     I  am  not 
prepared  to  say  that,  in  case  of  pericarditis,  or  of  pleuritis,  or  of 
peritonitis,  when  it  is  feared  that  adhesions  will  form  between 
surfaces  which  come  together,  and  by  which  the  organ  may  irre- 
trievably suffer,  perhaps  by  which  death  will  be  produced  (for,  in 
such  cases,  of  two  evils  I  would  choose  the  least) ;  but  I  do  say 
that  it  is  only  in  such  urgent  and  life-important  cases  that  mercury 
ought  to  be  given  to  salivation.     More  than  this,  I  expect  to  see 
the  day  when  even  in  such  cases  a  safer  remedy  will  be  invariably 
employed.     And  in  considering  this  question,  we  must  not  forget 
that,  even  after  coagulation  has  taken  place,  nature,  in  many 
instances,  alone  will  do  very  much. 

The  inflammation  ceased,  and  the  part  at  rest,  even  solidified 
fibrin  is  often  removed.  Of  course  when  the  heart  and  pericardium 
have  united  together,  or  the  pleura  costalis  is  adherent  to  tuo 
pleura  pulmonalis,  or  one  fold  of  the  peritoneum  to  another,  the 
constant  motion  of  the  parts  almost  precludes  the  possibility  of 
that  repose  without  which  repair  cannot  bo  effected.     But  even  in 


.* 


'!> 


ff 


In. 


Il 

'1 

■  ! 

■  r 

. .  i . . 


92 


PEINCIPLES    OF    SURGERY. 


?  , 


I-'    ,, 
111     '■ 


■;  !  i      I  i 


F    u  ^^ 


these  cases  nature  at  least  tries  to  ameliorate  the  evil ;  and  after 
a  time,  perhaps  very  lengthy,  the  bonds  of  union  are  very  much 
lessened,  although  not  removed.    For  instance,  in  granular  lids  of 
the  eye,  where  lymph  exists  to  a  considerable  extent  in  an  or- 
ganized form,  if  the  eye  be  kept  at  rest  for  some  time — perhaps  a 
long  time  may  be  required — nature  will  remove  the  adventitious 
material,  while  the  union  which  had  taken  place  between  the 
mucous  membrane  of  the  lid  and  that  of  the  eyeball  will  be  con- 
siderably reduced.     Under  such  circumstances  we  often  speak  of 
stimulating  the  abaorbents.     Elsewhere  it  has  been  shown  that 
stimulation  of  the  absorbents,  in  the  true  sense  of  the  term,  is 
inappropriate,  inasmuch  as  stimulation  of  the  vessels  would  only 
add  to  the  difficulty.     What  is  necessary,  and  what  the  surgeon 
can  only  wish  to  secure,  is  the  liquefaction  of  the  material,  and 
then  the  contact  of  it  with  the  absorbent  vessels ;  and  anything 
which  may  be  given  or  applied  must  be  in  accordance  with  these 
indications.     To  this  end  mercury  may  be  administered,  and  so 
may  the  iodide  of  potassium.     Of  the  latter  medicine  I  think  I 
cannot  speak  too  highly.     For  the  same  purpose  iodine  alone  is 
sometimes  given  and  applied  to  the  part.     However,  it  should  not 
be  done,  so  long  as  the  part  is  inflamed.     I  have  seen  a  large 
number  of  cases  in  which  the  tincture  has  been  applied  externally 
with  the  effect  of  rekindling  the  inflammation.     It  is  a  question 
whether  it  will,  when  applied  to  a  part,  have  any  direct  effect  upon 
the  absorbents.     I  am  disposed  to  believe  that  the  iodine,  when 
thus  used  on  the  skin,  unites  with  the  cuticle  and  forms  a  firmer 
covering,  by  which  a  degree  of  rest  is  secured,  and  at  the  same 
time  a  certain  amount  of  pressure  is  made,  whereby  the  material 
to  be  removed  is  brought  in  contact  with  the  coats  of  the  ab- 
sorbents.    There  is  at  the  same  time,  undoubtedly,  a  degree  of 
stimulation ;  and  hence  the  important  fact  that  it  should  never  be 
used  until  excitement  has  quite  subsided  ;  and  the  other  fact,  that 
iodine  is  more  useful  when  there  is  a  tendency  to,  or  actual  state 
of,  asthenic  action. 

Counter-irritation  is  of  great  value,  as,  for  instance,  in  granular 
lids  and  vascular  cornea,  a  blister  frequently  repeated  behind  the 
ear,  or  in  frorft  of  it,  or  perhaps  a  small  seton.  Also,  where 
adhesions  have  formed  between  the  pericardium  and  heart,  a 
seton  over  that  organ  will  often  divert  nature,  and  thus  obtain  a 


TREATMENT   OP   THE   PBODUCTS   OP   INFLAMMATION.      93 

degree  of  required  repose.  A  recent  and  more  acute  irritation 
engages  nature  in  one  respect,  while  in  another  respect  she  is 
relieved  of  a  degree  of  excitement  inimical  to  repair. 

Suppuration  will  prove  serviceable  in  some  cases.  If  the 
lymph  which  has  become  organized,  and  is  productive  of  evil,  can 
be  made  to  degenerate  into  pus,  a  step  is  thereby  made  toward  a 
return  to  fluidity.     (  Vide  Treatment  of  Pus.) 

Treatment  of  False  Hypertrophy  and  Induration^  and  Atrophy 
arising  from  a  deposit  of  inflammatory  lymph.— V(\iQn  false  hy- 
pertrophy results  from  inflammation,  that  is,  when  the  lymph 
which  has  been  thrown  out  becomes  incorporated  with  the  tissue 
by  organization,  the  question  arises  whether  the  surgeon  can  do 
anything  to  cause  or  hasten  its  removal.  It  will  be  necessary 
here  to  say  a  few  words  which  will  forestall  remarks  which  I  shall 
have  to  make  in  connection  with  the  healing  process. 

It  is  a  law  well  recognized,  that  in  the  body,  as  in  nature  gene- 
rally, like  begets  like;  that  every  tissue  in  the  human  fabric 
constantly,  as  parts  wear  out  and  die,  beget  other  like  structures : 
this  we  have  learned.  Now  when  inflammatory  lymph  w  effused, 
and  becomes  organized,  it  possesses  no  such  vital  powers.  The 
adventitious  matter,  it  is  true,  possesses  a  certain  degree  of  vital- 
ity, so  that  it  lives  for  a  time,  occasionally  for  a  long  time ;  but 
when  it  does  die,  no  other  like  material  is  begotten  to  take  its 
place,  unless  it  be  derived  from  the  blood,  and  is  a  product  of 
continued  inflammation.  Thus  we  find  that  fibrin,  as  a  product 
of  inflammation,  if  it  coagulates  and  does  not  subsequently  reli- 
quefy,  remains  in  the  part  until  it  lives  its  period  of  life,  when, 
being  removed  by  the  absorbents,  in  accordance  with  physiological 
laws,  there  gradually  take  its  place  the  natural  tissues  of  the 
part. 

In  these  cases,  it  will  be  seen  that  time  is  required  to  restore 
the  part ;  and,  I  will  repeat,  that  quietude  is  of  supreme  import- 
ance. We  understand  now  the  doings  of  nature  when  lymph  has 
become  organized ;  it  matters  not  whether  it  be  a  case  in  which 
there  is  no  perceptible  change  of  form,  or  it  be  hypertrophy,  or 
induration,  or  a  certain  form  of  atrophy.  Bearing  in  mind  these 
doings  of  nature,  it  is  the  surgeon's  only  duty  tD  try  to  assist 
her;  and  what  has  been -recommended  heretofore,  will  in  all  cases 
be  trusted  to  as  the  surest  way  in  which  to  render  service. 


m 


94 


PRINCIPLES    OF    SURGERY. 


Treatment  of  Degenerated  Inflammatort/  X?/m;)/t.— Inflamma- 
tory lymph  may  undergo  several  forma  of  metamorphosis,  com- 
monly called  degeneration.  Perhaps,  with  but  few  exceptions,  all 
forms  of  metamorphosis  which  are  not  of  development,  are,  at 
the  same  time,  degenerative  changes  ;  that  is  to  say,  when  a  tissue 
or  an  individual  cell  becomes  changed,  it  assumes  a  lower  place  in 
the  scale  of  animal  life,  and  at  the  same  time  has  taken  a  first 
step  towards  ultimate  death. 

We  have  seen  that  inflammatory  lymph,  which  is  itself  an  ab- 
normal material  resulting  from  inflammatory  action,  and  which 
possesses  a  certain  degree  of  vitality,  may,  to  a  limited  extent, 
become  developed,  and  for  a  time  form  a  part  of  the  body.  On 
the  contrary,  under  certain  circumstances,  it  is  found  to  degenerate 
into  one  of  several  forms.  Paget  speaks  of  the  following,  viz. : 
Into  a,  1st,  horny  substance;  2d,  fatty  degeneration;  3d,  calcare- 
ous degeneration;  4th,  "pigmental  degeneration  of  fibrinous 
lymph,  in  the  various  shades  of  gray  and  black,  which  often  per- 
vades the  lymph  formed  in  peritonitis." 

Treatment  of  Pm8.— Degeneration  of  lymph  into  pus  is  by  far 
the  most  frequent ;  indeed,  it  is  the  only  one  to  which  we,  as  sur- 
geons, need  particularly  direct  our  attention.  It  is  in  reality  a 
tatty  degeneration.  Oil  globules  cannot  always,  it  is  true,  be  seen 
in  the  pus-cells,  especially  when  recent ;  but  they  will  soon  begin 
to  show  themselves.  It  is  difiicult  to  draw  the  line  of  demarcation 
between  the  cell  of  inflammatory  lymph  and  the  cell  of  pus,  al- 
though there  is  no  doubt  that  the  former  is  gradually  converted 
into  the  latter.  It  may  with  safety  be  said,  however,  that  when 
oil  globules  are  detected  in  the  cell,  it  is  no  longer  a  lymph-cell, 

but  a  pus-cell. 

It  is  desirable  to  re-state  here  the  important  fact,  that  these 
degenerative  changes  in  the  lymph  are  seemingly  so  many  steps 
taken  by  nature  to  get  rid  of  the  material  which  has  resulted  from 
the  inflammatory  action.  And  this  brings  me  to  the  statement 
that  pus  may  be  absorbed.  It  is  an  old  doctrine,  and  one  which 
may  not  easily  be  cast  aside,  that  pus  cannot  be  absorbed.  Cer- 
tainly, pus-cells  are  too  large  to  be  taken  up  by  the  absorbents ; 
but  we  have  ascertained  that  pus-cells,  as  they  grow  old,  gradually 
enlarge,  while  the  oil  globules  form  within.     At  last  the  wall, 


i' 


TREATMENT   OP  THE   PRODUCTS   0.^   INFLAMMATION.      95 


having  become  thin,  breaks  down ;  and  thus  it  is  that  pus  is  gra- 
dually prepared  to  be  taken  away  by  the  absorbents. 

Pus,  it  has  been  stated,  may  form  in  three  ways :  1st,  in  the 
form  of  an  abscess,  circumscribed ;  2d,  diffused  in  the  cellular  tis- 
sue ;  3d,  upon  the  surface  of  a  membrane. 

Now  we  will  suppose  that  a  certain  tissue  has  been  inflamed. 
The  disease  has  subsided,  or,  perhaps,  even  while  it  continues, 
there  exists,  as  a  product  of  the  inflammation,  a  quantity  of  coagu- 
lated lymph.  The  cellular  tissue  has  been  pressed  together  and 
aside,  and  within  the  tissue  is  this  adventitious  material.  Too 
great  in  quantity  to  be  supplied  with  bloodvessels,  it  is  doomed  to 
die ;  not,  however,  at  once,  but  by  that  gradual  process  of  degene- 
ration which  has  been  described  above,— a  fatty  degeneration,  re- 
sulting in  actual  death  of  the  component  cells.  In  this  case  we 
have  supposed  that  the  lymph  became  at  first  a  coagulated  mass, 
and  afterward  degenerated  into  pus.  Such  is  very  likely  to  be 
the  course  when  an  abscess  forms,  but  it  is  not  always  the  case ; 
instead,  the  lymph  may,  after  being  eff"used,  pass  into  the  form  of 
pus,  not  having  previously  coagulated. 

Taking  the  mass  of  solidified  fibrin,  it  is  found  that,  as  a  general 
thing,  the  degeneration  commences  at  the  centre  of  the  mass.  This 
is  the  oldest  portion  of  the  clot  and  the  farthest  removed  from  the 
sources  of  vitality,  and  may  be  expected  to  first  yield  to  the  de- 
generating process.  The  softening  gradually  extends  from  the 
centre  towards  the  circumference,  until  the  whole  mass  is  softened. 
But  the  surrounding  tissue,  in  which  is  infiltrated  the  lymph,  and 
which  is  more  or  less  condensed  by  pressure,  will  form  a  very  per- 
fect barrier,  by  which  the  pus  is  completely  inclosed,  and  by  which 
the  outside  tissue  is  in  many  cases  protected  from  the  encroach- 
mg  pus.  When  an  abscess,  then,  is  fully  formed,  there  is  in  the 
centre  the  fluid  ;  around  this  a  hardened  barrier  of  lymph  and  tis- 
sue ;  and,  without  the  barrier,  the  tissue,  in  most  cases,  is  very 
much  congested.   (Sec  diagram,  p.  96.) 

The  Process  of  Pointing.— The  process  of  degeneration,  cha- 
racterized by  increase  in  size  of  the  lymph-cells,  and  a  general 
mcrease  of  the  contents,  causes  pressure  from  within.  This  pres- 
sure is  equal  in  every  direction ;  consequently,  upon  that  side 
where  there  is  the  least  resistance,  the  pus  will  gradually  make  its 
way.     Hence  it  is  that  pus.  as  a  ereneral  thinir.  finrls  Jt.«  wq^  to 


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PRINCIPLES    OP    SURGERY. 


the  surface  of  the  body.  But  if  a  resisting  membrane,  or  a  fascia 
intervene  between  the  collecting  pus  and  the  surface,  then  it  will 
burrow  in  some  other  direction,  where  there  is  less  to  obstruct  its 


II 


way.  Again,  sometimes,  when  the  abscess  is  located  in  an  internal 
organ,  as  the  liver,  the  matter,  instead  of  approaching  the  surface 
of  the  body,  takes  a  more  easy  course  into  the  intestinal  track,  or 
perhaps  a  more  lengthy  route ;  yet,  nevertheless,  a  more  easy  one. 
While  writing  this,  I  have  under  u.y  care  a  man  with  unmistakable 
symptoms  of  abscess  of  the  liver,  the  pus  of  which  found  an  outlet 
by  way  of  the  left  lung,  through  the  bronchial  tubes.  There  is 
one  general  law  always  manifested,  namely,  the  pus  does  not  take 
the  nearest  way,  but  the  easiest^  to  obtain  its  escape.  There  might, 
seemingly,  be  an  exception  to  this  law,  as  exhibited  in  the  fact 
that  abscesses,  although  near  to,  rarely  open  into  a  serous  sac, 
notwithstanding  the  resistance  cannot  be  said  to  be  very  great. 
But  in  these  cases  a  wise  and  preservative  law  of  nature  shows 
itself — one  before  referred  to — namely,  that,  in  connection  with 
inflammation  of  serous  structures,  the  tendency  is  to  adhesion. 
Inflammatory  action  must  precede  the  formation  of  pus.  Now,  if 
that  action  begets  a  layer  of  highly  organizable  lymph,  as  it  will, 
upon  a  serous  membrane,  the  part  is  thereby  strengthened,  and  a 
barrier  is  formed  which  will  generally  resist  any  advances  in  that 
direction.  There  are  some  tisttuea  which  possess  the  ability  lo 
resist  the  pressure  made  by  pus,  so  that  it  may  actually  bathe 
them ;  for  instance,  the  coats  of  bloodvessels  are  rarely  affected 


TREATMENT  OF  THE  PRODUCTS  OF  INFLAMMATION.   97 

by  abscess.  They  are,  as  a  general  thiHg,  pressed  aside  by  the 
lymph ;  but  they  have  been  known  to  traverse  an  abscess  and  yet 
remain  unaffected.  If,  however,  the  coats  be  examined,  they  will 
be  found  thickened,  as  if  a  coating  of  lymph  had  been  formed 
around.  And  so  it  may  be,  after  all,  that  the  vessel  owes  its  pre- 
servation, not  to  the  powers  of  resistance  in  the  tissue,  so  much  es 
Its  ability  to  supply  in  this  contingency  lymph  of  high  vitality. 

The  pointing  of  an  abscess  can,  from  the  foregoing,  be  readily 
understood.    Pressure  upon  any  tissue,  if  continued  for  a  sufficient 
length  of  time,  will  cause  its  destruction.     The  pressure  produces 
an  early  death  of  the  ultimate  particles  of  the  tissue,  which  seems 
to  be  attended  with  a  degree  of  softening,  and  the  debris  is  carried 
away  by  the  absorbents,  while  there  is  not  that  ordinary  repair 
which  takes  place  in  a  state  of  health.     The  result  is  that  the  tis- 
sue  IS  gradually  eaten  away  until  finally  the  pus  breaks  through 
and  escapes-the  pointing  process  is  completed.     Thereupon  the 
pus  within  IS  discharged  until  the  pressure  is  relieved.     The  tis- 
sues which  had  been  thrust  aside  will  gradually  resume  their  proper 
position,  and,  if  the  opening  be  sufficiently  large,  the  contents  of 
the  abscess  will  entirely  flow  away. 

While  the  pus  is  thus  escaping  from  the  abscess,  the  walls,  com- 
posed of  lymph  and  cellular  tissue,  will  be  found  to  undergo  cer- 
tain changes  The  lymph  will,  to  a  great  extent,  degenerate  into 
pus;  the  cellular  tissue  will  either  die  and  mingle  with  the  pus  in 
the  form  of  debris,  or  recover  its  vitality ;  this  will  depend  upon 
the  degree  of  pressure  to  which  it  had  been  subjected.  Around 
where  the  barrier  was,  physiological  action  will  take  the  place  of 
pathological.  And  upon  the  inner  surface  of  the  walls  will,  in  due 
time,  be  found  granulations  and  extraordinary  repair  taking  place 

nrt^'^JV^'  '"''^^  '''"^^'"6  ^'•^'"  ^^'  discharged  abscess! 
{  Vide,  the  Healing  Process.) 

These,  then,  are  the  steps,  either  one  of  which  maybe  taken  by 
nature  to  get  rid  of  pus,  when  it  results  from  inflammatory  action 
namely,  liquefaction,  degeneration,  until  the  cell-wall  breaks  down' 
thereby  allowing  it  to  be  absorbed  ;  or,  if  this  be  impossible,  from 
the  quantity  of  pus,  or  from  the  continuation  of  the  exciting 
cause,  then  steps  arc  promptly  taken  to  dispose  of  it  in  a  more 
Bummary  manner  by  the  process  of  pointing. 

Such  are  the  workings  of  nature,  and  hereby  must  the  surgeon 

1 


98 


PRINCIPLES    OF    SURGERY. 


w 

t 


be  guided  in  any  step  he  may  propose  to  himself  to  take  in  ren- 
dering assistance.  In  two  general  ways  he  may  assist.  Possibly 
he  may  remove,  or  limit  the  cause  of  the  formation  of  pus — may 
cut  off  the  source  of  supply,  break  a  link  in  the  chain  of  morbific 
causes,  whereby  the  part  will  be  placed  in  a  condition  favorable  to 
restoration ;  or,  if  this  be  impossible,  if  the  matter  will  continue 
to  collect,  and  will  find  its  way  by  pointing  to  the  surface  to  es- 
cape, then  there  is  a  second  way  in  which  the  surgeon  may  assist. 
It  is  possible  to  abridge  the  process  of  pointing,  and  instead  of 
allowing  those  hours  and  days  of  painful  work,  which  attend 
nature's  doings,  to  make  an  opening  for  the  pus  to  escape,  the 
surgeon  should  divide  the  tissues  by  the  knife. 

Poulticing  and  hot  applications  may,  by  softening  the  tissue, 
and  soothing  the  irritated  nerves,  do  some  good ;  but,  when  pus  is 
known  to  exist,  there  should  be  no  hesitancy  in  promptly  making 
an  opening  for  the  pus  to  escape.  More  than  this,  it  is  better  to 
err  on  the  safe  side,  by  making  too  early  an  incision — that  is, 
before  the  pus  really  exists — as  the  incision  can  do  no  harm,  while 
it  may  so  relieve  the  part  of  congestion  that  suppuration  will  be 
averted. 

The  instrument  with  which  the  opening  should  be  made  will 
depend  upon  the  position  of  the  abscess,  and  its  depth.  If  the 
wall  be  thin,  the  most  convenient  instrument  is  the  abscess,  or  the 
ordinary  lancet ;  when  it  is  deeper  seated,  a  stout  bistoury  will  be 
required  to  cut  through  the  intervening  tissue;  and  when  the 
abscess  is  somewhat  elevated  above  the  surrounding  surface,  as  in 
a  bubo,  the  most  convenient  instrument  is  the  curved  bistoury. 
This  must  be  made  to  transfix  the  elevated  walls  to  a  sufiiclent 
extent,  and  then  to  cut  its  way  upwards  so  as  to  divide  the  inter- 
vening tissue.  When  the  abscess  is  deep-seated,  there  is  danger 
that  the  wound  made  may  close  again,  after  some  of  the  matter 
has  escaped ;  to  prevent  this,  a  piece  of  lint  must  be  introduced, 
and  allowed  to  remain  at  least  till  the  following  day.  (Hilton's 
Method  of  Opening ;  Lancet,  1860,  vol.  xi,  p.  454.) 

I  wish  here  particularly  to  point  out  the  evil  of  a  practice,  a  long 
time  in  vogue,  and  yet  practised  by  many  high  in  authority.  1 
refer  to  the  custom  of  squeezing  out  the  pus  after  the  abscess  has 
been  opened.  It  is  not  only  unnecessary,  but  as  it  is  actually 
painful,  therefore  it  is  objectionable.     Nothing  can  be  advanced 


TEEATMENI  OF  THE  PRODICIS  OF  INFIAMMAIION.      99 

to  rapport  the  practice,  unless  it  be  that  it  is  gratifviog  to  the 
surgeon  to  see  the  amount  of  matter  for  which  he  has  provided  a 
way  of  escape.    The  surgeon',  only  duty  is  to  secure  a  free  open- 
.ng,  and  then  treat  w„h  the  view  to  arrest  the  formation  of  any 
more  pus:  an  end  which  will  not  be  reached  by  pressing  outZ 
pus  and  pnttmg  the  patient  to  pain.     Therl  is  .Iwfys  oJh 
enough  of  .rntafon  and  pain  attending  the  operation   without 
unnecessarUy  increasing  it.     To  allay  thh  irritation,  wl  appl" 
cafons  may  be  used,  first  in  the  form  of  WBrm  water,  and  afte  - 
wards  by  a  pou  tjce  of  linseed  meal;  and  this  latter  will  also 
secure  a  gradual  but  free  evacuation  of  the  abscess.    Following 
closely  upon  the  heel  of  this  will  be  the  first  steps  of  the  "healf 
process;     not  .ndeed,  but  that  everything  thSs  far  has  been  f 
process  of  heahng.     All  that  the  surgeon  can  have  done  was  to 
g.ve  assistance  to  a  natural  process.     But  very  soon  he"  ing  n  a 
More  percept. He  manner  commences.     The  pLltice  3  had 
been  apphed  should  be  discontinued,  not  to  V,/ again  used,  unless 
from  some  cause,  the  pus  should  begin  to  collect;  under   uch  c  r 
cun>stances,  a  poultice  may  to  advantage  be  at  least  appi  ed  at 
night  and  removed  in  the  morning.  ^^ 

We  arc  now  on  the  boundaries  of  another  subject,-that  of  the 
healmg  process,  which  has  to  receive  a  separate  consideration 
Suffice  .t  to  say  here,  that  nothing  can  be  done  by  the  surron  to' 
make  a  part  heal;  it  is  a  natural  process,  and  all  Lt  can  be  don 
.so  keep  the  part  in  such  a  position  as  will  allow  nature  to  work 
wuhout  embarrassment.    To  accomplish  this,  all  that  i,  neoesia  y 

tV  Yr"  "'  ™'  """^  P'"'™'  "  ^y  water-drcssing.       ^ 

The,econd  form  m  which  pus  is  met,  is  where  it  is  diffused 

« :::  mt^^  fr':v "° """-  °f  '^-p-  ^-j  -densfd 

tissue.     The  lymph  which  has  .legeneratcd  into  pus  occupies  the 
tssue  in  small  quantities;  it  is  distributed  in  thLcIluTarTaoes 
Bc^eneration   takes  place  simultaneously  in  several  of  These 
Sometimes,  as  it  collects,  several  of  them  will  coalesce.    Bu 

s„  ct"  T     r  °'  ™""™''™^  ""I'te  an  abscess,  in  every 
rosp  ct.    A  single  opening  will  not  secure  a  discharge  of  the  pus 

hi    it  m  '    """J-V™"  ?»">"'  constitutional  cause;  so  much  so, 
that  It  may  he  looked  upon  as  a  variety  of  infiammation.     The 


100 


PRINCIPLES    OP    SURGERY. 


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treatment  is  the  same  as  that  pursued  in  certain  forms  of  erysipe- 
las.    ( Vide  that  disease.) 

Pus,  which  forms  upon  a  mucous  membrane,  may  in  many 
respects  be  regarded  as  mucus  in  an  altered  state.  The  blood 
which  normally  circulates  in  the  part,  and  from  which  the  mucus 
is  secreted,  coming  thereto  with  unusual  rapidity,  gives  rise  to  the 
phenomena  of  inflammation.  Transudation,  at  first  arrested,  soon 
takes  place  in  increased  quantity ;  but  now,  instead  of  mucus,  it 
possesses  rather  the  characteristics  of  pus.  Or  it  may  be,  that 
while  some  of  the  fluid  forming  upon  the  surface  is  decidedly  pur- 
ulent, other  portions  retain  the  nature  of  mucus. 

The  treatment  to  be  observed  is  obvious.  There  is  too  much 
blood  going  to  the  part ;  this  is  due  to  some  irritation.  The  first 
consideration  is  to  effect  the  removal  of  the  irritating  cause,  what- 
ever it  may  be :  whether  a  poison,  as  in  gonorrhceal  conjunctivitis; 
or  continued  motion,  which  so  frequently  keeps  up  inflammation  of 
the  eyes;  the  cause  must  be  removed.  Then,  the  blood  circu- 
lating normally,  the  pus  will  gradually  cease  to  form,  and  the 
function  be  restored.  If  the  inflammation  have  continued  for  a 
long  time,  the  membrane  may  have  become  so  changed,  that, 
although  the  cause  is  removed,  the  pathological  state  will  remain 
for  an  uncertain  period  of  time. 

Mucus  as  a  product  of  inflammation  requires  no  separate  atten- 
tion. Every  principle  as  to  pathology  and  treatment  has  already 
been  considered  under  "  Pus  upon  the  surface  of  a  mucous  mem- 
brane." 

Blood  is  the  only  remaining  product  of  inflammation.  Inas- 
much as  it  demands  no  special  attention  in  the  way  of  treatment, 
it  need  not  here  be  discussed. 


d        I     OS 


'Hi 


DISEASES    ARISING    OUT    OF    INFLAMMATION.        101 


CHAPTER    XII. 

Diseases  arising  out  of  Inflammation  — Passive-     1    rn„„«  ♦•         t.      , 
Treatment,  Local  and  General       2   rv.  t  l'  ^<'°^^«*^°'^ 5  Results- 

Treatment.  ^^  ^^'°°'"  Inflammation;   Products- 

There  are  certain  conditions  frequently  seen  in  connection 
with,  or  arising  out  of,  the  inflammatory  process,  which  have 
generally  been  considered  in  connection  with  it,  and  which  are 
called  remote  products  of  inflammation.    These  conditions  possess 
distinctive  features,  in  which  can  be  seen  the  morbid,  prepondera- 
tmg      There  is  more  of  the  pathological  than  of  the  physiological. 
The  inflammatory  process,  such  as  we  have  endeavored  to  trace 
and  whose  footsteps  we  have  closely  followed,  has  been,  in  the 
main,  on  physiological  grounds.     And  all  along  the  way,  we  have 
seen  evinced  the  most  judicious  and  successful  arrangements  of 
nature  to  effect  a  cure.    But  we  now  must  turn  into  another  path, 
in  which  nature  s  efforts  seem  to  a  great  extent  abortive,  in  which 
physiolog'at""'  ^'^^^"^-^^^^^  *^«  P^*»-^«g-l  -Persedes  the 
This  plan,  although  novel,  will,  I  think,  simplify  the  matter  for 
ho  student-an  object  I  have  steadily  in  view;  for  I  hold  that  in 
the  medical  profession  there  is  more  to  learn  than  can  well  be 
,acquii-ed,  and   that  the  road  ought  to  be  made  smoother  and 
smoother  by  each  traveller  as  he  passes  along. 

The  diseases  arising  out  of  inflammation  are:  1.  Passive 
Congestion  2.  Chronic  Inflammation.  3.  Chronic  Abscess.  4. 
Pyemia.  5  Softening.  6.  Ulceration.  7.  Sloughing.  8.  Gan- 
grene.    9.  Induration.     10.  Hypertrophy.     11.  Atrophy. 

It  IS  impossible  to  draw  a  distinct  line  of  demarcation  between 
healthy  inflammation  and  unhealthy-between  healthy  products 
and  those  which  are  otherwise.  Hence  it  was,  that  induration, 
hypertrophy,  and  atrophy  received  attention  in  connection  with 
healthy  inflammation,  however  at  times  they  do  present  more  the 
characteristics  of  disease  than  of  healthy  action. 
Passive  Congestion.-In  this  disease,  there  is  too  mucb  hlnorl  ;. 


102 


PRINCIPLES    OP    SURGERY. 


the  part  affected ;  not  because  there  is  too  large  a  quantity  sent, 
but  because  it  cannot  flow  therefrom  in  a  normal  manner.  Here 
is  a  condition  widely  different  from  that  which  has  been  described 
as  active  congestion.  The  vessels  which  are  engaged  belong  rather 
to  the  venous  system ;  the  blood  within  them  is  venous. 

Causes. — Two  general  causes  may  be  specified :  1st,  obstruction 
to  venous  return ;  2d,  a  toneless  condition  of  the  vessels  and  parts 
generally.  The  obstruction  may  exist  immediately  at  the  part,  or 
it  may  be  more  remote.  Taking  the  foot  for  example,  if  it  be  the 
seat  of  passive  congestion,  the  cause  thereof  may  be  found  close 
by,  at  the  ankle,  or  at  the  knee,  or  even  at  the  pelvis.  Many 
causes  of  mechanical  obstruction  may  be  enumerated — such  as 
external  pressure,  in  the  form  of  a  garter  around  the  leg ;  or  a 
tumor  may  press  upon  the  vein  so  as  to  retard  the  flow.  The 
gravid  uterus  may  press  upon  the  pelvic  portion  of  the  vein ;  or  a 
cirrhosed  liver  may  diminish  the  calibre  of  the  vein.  Any  one  of 
these  may  be  a  cause  of  passive  congestion  of  the  limb. 

The  congestion  may  result  from  a  relaxed  condition  of  the  part, 
or  a  dilated  state  of  the  capillaries.  Not  unfrequently,  inflamma- 
tion of  the  acute  kind  is  succeeded  by  passive  congestion  in  the 
part,  the  inflammation  having  been  the  cause  of  the  dilatation. 
The  congestion  may  thus  be  due  to  some  local  defect  or  disease ; 
or  it  may  arise  from  some  constitutional  evil,  with  or  without  some 
local  exciting  cause.  Whatever  may  have  been  the  cause  of  the 
passive  congestion,  the  phenomena  by  which  it  is  characterized 
are  quite  unlike  those  of  active  congestion. 

Symptoms  and  Diagnosis, — As  the  pathology  differs  from  that 
of  active  congestion,  so  do  the  symptoms.  To  distinguish  between 
them,  the  surgeon  has  only  to  remember  the  following  symptoms 
and  diagnostic  marks.  In  the  first  place,  the  history  of  the  case 
is  widely  different.  Then  the  influx  of  blood,  in  the  passive  form, 
is  more  general,  and  the  swelling  is  more  distributed.  It  produces 
what  may  properly  be  called  an  enlargement — instead  of  a  swell- 
ing— which  will  from  time  to  time  be  diminished,  or  will  disappear. 
The  pain  is  not  acute,  and  sometimes  is  intermittent.  Instead  of 
redness,  there  is  often  an  absence  of  the  ordinary  color;  some- 
times, however,  it  is  increased,  but  the  redness  is  of  a  darker  hue 
than  is  seen  in  the  active  form.  There  may  at  times  be  a  sensa- 
tion of  unusual  heat,  but  nothing  like  that  burning  sensation  which 


DISEASES    ARISING    OUT    OF    INFLAMMATION.        103 

belongs  to  the  active  form.  The  function  of  the  part  is  more  or 
less  deranged;  this  necessarily  ensues  upon  the  dilatation  of  the 
venous  capillaries.  The  progress  of  the  blood  through  them  is 
very  slow,  and  consequently  the  arterial  blood  cannot  flow  into 
the  part,  even  to  supply  nutrition.  Function  is  thus  deranged, 
and  ultimately  vitality  of  the  tissue  is  impaired.  That  continued 
passive  congestion  does  impair  the  vitality,  is  shown  very  often  in 
chronic  ulcers  of  the  legs.  ( Vide  Ulcers.)  If  from  any  cause 
the  tissue  IS  mjured,  the  powers  of  nature  fail  to  repair  it  as  in 
health. 

Passive  congestion  may  be  called  a  local  affection  ;  at  least,  for 
some  time,  it  gives  rise  to  no  constitutional  symptoms.  There  is 
nothing  like  irritative  fever,  such  as  is  seen  in  active  congestion. 
If,  however,  the  disease  continue  for  a  long  time,  general  weak- 
ness,  failing  appetite,  and  sleeplessness,  may  be  expected  to  result. 
Itesults  of  Passive  Congestion.— The  principal  result  is  effusion 
of  serum.  The  watery  state  of  the  blood,  its  sluggish  movements, 
as  well  as  the  weakened  state  of  the  tissue,  favor  transudation 
through  the  coats,  producing  dropsy  or  anasarca. 

Softening  of  the  tissue  is  another  result.  ( Vide  Softening.)   And 
the  tissue  may  undergo  also  other  deteriorating  changes. 

Treatment.— In  no  case  of  disease  is  the  principle  that  it  is 
necessary  to  remove  the  cause  so  apparent  as  in  this.  If  there  be 
any  obstruction  to  the  venous  flow,  it  is  of  paramount  importance 
to  have  it  removed ;  and  then,  if  the  congestion  be  not  of  long 
standing,  restoration  will  soon  follow.  Again,  if  the  disease  is 
connected  with  a  toneless  condition  of  the  tissue,  endeavor  to 
ascertain  what  was  the  cause  thereof;  and  then,  to  effect  its 
removal,  understand  whether  the  fault  lies  in  the  tissue  of  the 
part,  which  therefore  does  not  possess  the  power  to  appropriate 
from  the  blood  to  maintain  ordinary  repair,  or  whether  the  blood 
itself  is  deficient  in  the  necessary  vital  elements.  If  a  satisfactory 
conclusion  can  be  arrived  at  relative  to  these  questions,  the  course 
of  treatment  to  be  pursued  will  be  surely  indicated. 

Speaking  generally,  the  treatment  will  be  both  local  and  general. 
The  bloodvessels  are  dilated,  and  will  be  benefited  by  external 
support.  In  case  of  venous  congestion  of  a  leg,  a  bandage  ap- 
plied in  the  morning,  before  swelling  takes  place  from  the  blood 
gravitating,  will  prevent  its  taking  place,  and  often,  after  a  time, 


104 


PRINCIPLES    OP    SURGERY. 


!llt' 


mu 


i  .1 


ili     .1 


even  effect  a  cure.  The  bandage  must,  of  course,  be  applied  from 
the  foot,  so  as  to  make  the  pressure  equal.  An  elastic  stocking 
may  be  advantageously  used  instead,  thereby  obviating  the  neces- 
sity of  the  daily  attendance  of  the  surgeon.  Yet  a  nurse  may  be 
taught  to  apply  it. 

Position  is  another  important  means  by  which  the  congestion 
may  be  controlled.  As  blood  will  gravitate  to  the  part,  so  it  may 
be  made  to  gravitate  from  it.  Bathing  and  friction  must  not  be 
neglected. 

The  constitutional  treatment  must  be  tonic,  of  which,  prepara- 
tions of  iron  will  be  found  the  most  serviceable ;  also  the  iodide  of 
potassium.  In  the  treatment  of  passive  congestion  of  the  spinal 
cord.  Dr.  Brown  Sequard  highly  recommends  belladonna,  and 
ergot  of  rye.  The  former,  he  has  found  by  experiments  on  the 
lower  animals,  has  a  very  decided  effect  upon  the  unstriped  mus- 
cular fibre.  It  may  be  given  internally,  or  applied  externally  in 
the  form  of  a  plaster.  I  have  used  it  to  great  advantage  in  pas- 
sive congestion  of  the  leg.  In  the  treatment  of  chronic  sores,  I 
use  the  extract,  to  which  water  is  added,  so  as  to  form  a  lotion. 
In  some  cases  I  have  added  Tinct.  Ferri,  by  which  the  lotion  was 
evidently  made  more  potent.  ( Vide  Carbuncle.)  It  is  hardly  neces- 
sary to  say  that  due  attention  must  be  paid  to  diet. 

Chronic  Inflammation. — So  called,  often  after  acute  inflamma- 
tion has  existed  in  a  part.  It  may  be  gradually  superseded  by  a 
pathological  condition,  which,  although  commonly  known  as  chronic 
inflammation,  possesses  very  few  of  the  features  of  inflammatory 
action.  Indeed,  when  such  features  do  show  themselves,  they  may 
be  regarded  rather  as  a  returning  to  the  primary  action.  The 
chronic  disease  seems  from  time  to  time  to  create  inflammatory 
action — perhaps  even  produced  it  in  the  first  instance. 

Causes. — Are  general  and  local.  In  every  case,  a  general  or 
predisposing  cause  may  be  said  to  have  been  in  operation.  Some- 
times two  or  more  predisposing  causes  have  acted  conjointly. 
These  gojieral  causes  may  be  some  morbid  condition  of  the  blood, 
or  of  the  tissue ;  either  may  have  been  of  long  standing,  or  of 
recent  existence ;  and  they  may  be  hereditary  or  acquired.  The 
more  potent  the  general  cause  or  causes,  a  less  exciting  cause  will 
be  adequate  to  produce  the  disease.  Chronic  inflammation  bears 
almost  the  same  relation  to  passive  congestion  as  true  inflammation 


DISEASES    ARISING    OUT    OP    INFLAMMATION.        105 

does  to  active  congestion.  In  one  case,  the  action  is  governed  in 
a  great  measure  by  physiological  laws;  in  the  other,  it  is  all 
abnormal— pathological.  In  the  one,  efforts  to  heal  are  manifested 
at  every  step ;  in  the  other,  these  efforts  are  absent,  or  are  of  the 
most  futile  kind. 

Local  S^jmptoms.— The  local  symptoms  of  acute  or  healthy  in- 
flammation are  pain,  heat,  redness,  and  swelling.  Now,  if  we 
examine  the  local  symptoms  of  chronic  inflammation,  which  are 
analogous  to  those  of  the  acute,  we  shall  find  that  they  are  indeed 
but  the  analogues  of  healthy  inflammation.  The  pain  is  rarely 
great,  as  the  swelling  is  slow  in  taking  place,  and  the  nerves  are 
never  made  acutely  sensitive,  ffeat  is  never  increased  to  an  ap- 
preciable extent.  Rednesn  .  not  generally  well  marked ;  it  may 
be  present,  and,  when  it  is,  the  hue  is  much  darker ;  there  is  not 
that  bright  ^rterial  color  which  is  seen  in  acute  inflammation.  The 
swelling  is  generally  greater,  not,  however,  always  so.  It  is  more 
diffused,  and  is  due  to  effusion  of  serum. 

The  resemblance  between  the  constitutional  symptoms  of  chronic 
and  acute  inflammation  is  even  less.  Inflammatory  fever,  with  its 
various  characteristics,  is  never  seen.  The  excretions  are  not 
arrested.  Where  fever  is  present  it  will  be  in  the  form  of  hectic. 
There  may  be  great  debility,  due  to  the  disease  itself,  or  to  some 
pre-existing  condition  of  the  constitution,  which,  indeed,  may 
likely  have  been  the  cause  of  the  disease.  ' 

Products  of  Chronic  Inflammation.— M  would  naturally  be  sup- 
posed, from  the  pathological  state  of  the  part,  serum  is  the  prin- 
cipal product.  With  the  serum,  however,  fibrin  is  often  poured 
out ;  but  it  is  limited  in  quantity  and  deficient  in  vitality.  Its 
power  to  organize  is  far  less  than  that  witnessed  in  the  fibrin  of 
acute  inflammation ;  and,  when  it  degenerates  into  pus,  it  is  also 
below  par ;  it  is  not  laudable  pus. 

The  liquor  puris  is  in  excess  when  compared  with  the  cell  con- 
stituents, while  at  the  same  time  the  cells  are  wanting  in  the  cha- 
racteristics of  pure  pus. 

I  have  said  that  at  times  the  disease  will  give  place  to  action  of 
an  active  kind,  during  the  continuance  of  which  the  features  of  true 
inflammation  will  become  more  prominent.  Now,  at  such  times, 
fibrin,  in  larger  quantities,  and  with  more  plasticity,  will  be  ef- 
fused, and  will  assume  a  higher  state  of  organization.     In  some 


106 


PRINCIPLES    OP    SURGERY. 


Ill  J.V  ^ 

talis  1^1    ' 


J  "ill 


cases  these  periods  of  active  disease  ■will  be  of  frequent  occurrence, 
or  it  may  be  that,  simultaneously,  chronic  action  may  exist  in  one 
part,  and  active  disease  in  another.  The  result  of  this  will  be  that 
fibrin  of  a  more  organizable  character  will  be  eifused ;  and,  in  con- 
sequence of  the  very  chronic  disease  which  is  coincident,  it  is  en- 
abled to  assume  a  high  state  of  development,  that  is,  for  a  material 
such  as  it.  It  is  in  such  cases  of  chronic  inflammation  that  a  tis- 
sue or  organ  is  seen  to  become  enlarged.  The  adventitious  mate- 
rial becomes  incorporated  with  the  natural,  constituting  false  hy- 
pertrophy. Sometimes,  again,  while  this  process  of  organization 
is  taking  place  in  one  part,  in  another  the  lymph  may  be  degene- 
rating into  pus.  The  irritation  in  one  place  leads  to  the  continued 
formation  of  pus  ;  in  another  to  the  existence  of  false  hypertrophy. 
These  widely  different  proceedings,  although  coincident,  will  indi- 
cate how  abnormal  is  the  action ;  how  far  separated  from  healthy 
action  is  chronic  inflammation,  so  called.  The  occasional  attempts 
to  cure  but  show  how  incapable  is  nature,  unaided,  to  accomplish 
the  work. 

Treatment  of  chrome  injlammation  may  conveniently  be  divided 
into  general  and  local.  Sometimes  the  local  disease  will  demand 
immediate  attention ;  but,  while  such  is  being  given,  the  constitu- 
tion will  also  require  particular  attention.  In  most  cases,  how- 
ever, the  order  will  be  reversed,  the  constitution  must  receive  the 
first  attention.  After  it  has  been  brought  into  as  healthy  a  state 
as  can  be,  then  local  treatment  will  be  more  likely  to  have  effect ; 
yet,  in  the  mean  time,  the  local  symptoms  should  be  palliated. 

In  all  cases  the  treatment  must  be  supporting.  Whatever  may 
be  said  in  support  of  depletory  measures  in  acute  inflammation,  no 
ground  can  be  found  upon  which  to  base  such  treatment  in  the 
disease  now  under  consideration.  Tonics,  and  often  stimulants, 
will  be  diligently  used.  Diet  of  the  most  nutritious  and  digestible 
kind  will  be  given. 

The  local  treatment  bears  a  closer  resemblance  to  that  of  the 
acute.  Counter-congestion  will  not  prove  so  beneficial ;  but  local 
depletion  will  generally  be  serviceable.  It  draws  away  the  venous 
blood,  and  relieves  the  distended  vessels  and  the  intervascular  sub- 
stance. Blisters  are  of  more  certain  value ;  by  their  use  a  large 
quantity  of  the  serum  will  be  drawn  off,  likewise  giving  relief  of 
an  important  kind,  inasmuch  as  serum  constitutes  the  principal 


CHRONIC    ABSCESS. 


107 


product  of  the  disease.  Of  still  greater  value  in  many  cases  is 
the  formation  of  a  discharge,  as  by  the  issue  or  seton  or  moxa. 
The  benefit  of  these  is  strikingly  exhibited  in  chronic  inflammation 
of  the  knee  or  hip  joint.  In  these  diseases,  a  blister  kept  running 
for  a  lengthened  period,  or  a  continued  discharge  maintained  for  a 
long  time,  will,  by  diverting  nature,  attract  from  the  seat  of  dis- 
ease the  superabundance  of  blood ;  so  that  the  tissue  may  there- 
after recover  itself,  other  circumstances  being  favorable.  In  all 
cases  rest  to  the  part  must  be  strictly  secured,  which  alone  will 
often  be  sufficient  to  effect  a  cure.  (Hilton.) 


] 


CHAPTER    XIII. 

Chronic  Abscess — Results — Treatment — Sinus  or  Fistula — Treatment. 

Cause. — Chronic  abscess  is  a  very  common  result  of  chronic 
inflammation ;  it  is  called  chronic,  however,  because  the  pus  col- 
lects very  gradually,  as  well  as  very  stealthily ;  generally  without 
pain  or  other  symptom  to  warn  the  patient,  or  tell  the  surgeon 
of  its  existence.  A  chronic  abscess  may  result  from  the  acute, 
as  well  as  from  chronic,  inflammation.  Sometimes  the  inflam- 
mation having  subsided,  there  will  exist,  as  a  product,  a  quan- 
tity of  coagulated  fibrin ;  this  may  subsequently  become  a  source 
of  limited  irritation,  leading  to  the  gradual  formation  of  pus. 
Again,  tubercular  matter  may  have  been  deposited  in  a  tissue  and 
have  become  a  source  of  slow  suppuration.  And  again,  a  com- 
paratively slight  injury  may  have  produced  effusion  of  a  quantity 
of  lymph,  with  or  without  a  little  blood,  which,  although  coagu- 
lated, failed  to  become  organized ;  and  which,  after  a  little,  gradu- 
ally degenerated  into  pus. 

Pus. — The  -pus  of  a  chronic  abscess  is  never  laudable.  It  will 
have  character  given  to  it  by  any  constitutional  evil  that  may 
exist,  but  it  is  always  thinner,  more  watery ;  the  liquor  puris  being 
in  excess,  while  the  corpuscles  are  deficient  in  that  vitality  which 
is  seen  in  pure  pus. 

Symptoms. — The  symptoms  differ  widely  from  those  of  acute 


immi 


108 


PRINCIPLES    OP    SURGERY. 


I  %       «' 


m^W 


abscess ;  yet  enough  resemblance  exists  to  warrant  the  use  of  the 
term  abscess.  In  acute  abscess  there  is  always  pain,  sometimes 
of  the  most  excruciating  kind ;  but,  as  before  said,  there  may  be 
none  to  mark  the  commencement  and  increase  of  the  chronic  ab- 
scess. The  reason  is  plain ;  the  pus,  forming  gradually,  does  not 
cauf^e  that  sudden  pressure,  so  that  the  parts  may  accommodate 
themselves  to  the  forming  material,  which  could  not  be  done  if 
the  pus  were  suddenly  collected ;  and  thus  irritation,  pain,  and 
inflammation  do  not  come  in  a  train.  The  extent  to  which  the 
body  or  a  single  part  may  become  accustomed  to  the  presence  of 
a  new  formation,  such  as  a  tumor  or  a  collection  of  pus,  when  the 
growth  takes  place  slowly,  is  very  remarkable.  The  tissues  en- 
croached upon  give  place,  will  first  be  pushed  aside,  and  afterward 
undergo  absorption ;  so  that  but  a  feeble,  or  perhaps  no  warning 
voice  is  heard,  to  tell  of  what  may  be  a  grave  malady,  leading  to 
destruction  of  important  parts. 

Diagnosis. — Very  often  a  large  abscess  will  form,  or  a  tumor  grow 
to  a  large  size,  and  its  existence  be  unknown,  or  at  most  but  sus- 
pected, until  it  shows  itself  externally.  And  when  an  abscess  is  dis- 
covered by  the  eye  it  is  not  always  easy  to  diagnose  it  from  a  grow- 
ing tumor,  or  a  chronic  hernia,  or  an  aneurism.  The  location  of  a 
hernia  is  only  likely  to  be  where  protrusions  can  the  most  easily 
take  place ;  and  an  aneurism  can  only  exist  in  the  course  of  an 
artery ;  and  so  far  safe  assistance  is  obtained  in  making  a  diag- 
nosis. And  upon  these  circumstances  and  the  history  of  the  case 
the  surgeon  will  have  principally  to  depend.  When  pus  ap- 
proaches the  surface  the  sense  of  fluctuation  will  afford  great 
help ;  but  it  must  be  remembered  that  fluctuation  is  sometimes 
present  in  an  aneurism,  particularly  at  its  first  formation.  It 
would  be  a  frightful  mistake  to  cut  open  an  aneurism  ;  and  should 
the  surgeon  feel  disposed  to  pursue  the  treatment  of  opening  an 
abscess,  and  yet  have  some  misgivings  as  to  its  nature,  he  ought 
by  all  means  to  wait.  In  this  connection  I  am  reminded  of  a  case 
which  came  under  my  notice  in  the  country,  in  consultation.  It 
was  an  obscure  swelling  in  the  abdomen.  The  physician,  under 
whose  care  the  patient  was,  had  diagnosed  an  abscess,  and  wished 
to  make  an  incision  through  the  intervening  tissue.  This  proce- 
dure was  objected  to  by  two  others  in  consultation.     The  patient 

ultiiuatclY  died,  whcn   Vk  j^Oii  vlOrtcTil  FcVcalcu  XiXdX  tu€  tUuiOI  naS 


CHRONIC    ABSCESS. 


109 


produced  by  an  encephaloid  growth  of  the  kidney.  Had  the  phv. 
sician,  who  was  one  of  some  forty  years'  practice,  aade  his  inci- 
sion where  he  proposed,  he  would  have  cut  through  the  omentum 
and  colon. 

Frognoais.—mil  necessarily  depend  upon  the  region  in  which 
the  abscess  is  located;  the  tissue  involved;  the  original  cause;  the 
constitution;  whether  afflicted  with  any  special  disease;  the  age; 
and  the  surroundings  of  the  patient. 

Results.— Resolution  may  take  place,  or  the  pus  may  find  its 
way  through  the  tissue  and  be  discharged.     That  resolution  may 
be  possible,  the  source  of  the  constantly  collecting  pus  must  be 
dried  up— the  cause  of  its  formation  must  be  removed.     There  is 
always,  .ur^-ounding  the  pus,  a  well-developed  pseudo-membrane  • 
this  IS  formed  m  part  by  condensed  cellular  tissue,  and  in  part  of 
organized  lymph.     It,  after  a  time,  is  well  supplied  with  blood- 
vessels.     The  lymph  which  separates  from  the  blood  in  this  sur- 
rounding false  membrane,  quickly  degenerates  into  pus,  and  is 
added  to  that  within  the  walls.     The  amount  of  pus  thus  formed 
will,  of  course,  depend  upon  the  degree  of  irritation.     The  mem- 
brane IS  called  the  pyogenic  membrane.     Now,  supposing  the  pus 
ceases  to  be  formed,  can  that  within  the  membrane  be  removed  by 
absorption  ?     The  belief  was  held  for  a  long  time  that  it  could 
not;  at  least  such  was  believed  by  many,  and  such  was  taught 
when  T  was  a  student.    But  the  teachings  of  Hilton,  in  his  recent 
lectures,  are  so  plainly  to  the  contrary,  and  are  so  well  supported 
by  Che  re.  ord  of  several  cases,  that  no  doubt  can  be  entertained 
as  to  the  ability  of  nature  to  remove  it.     The  same  membrane 
which  had  seemingly  secreted  pus,  assumes  a  new  office,— that  of 
absorbing  the  pus;  and  as  liquef active  degeneration  is  consum- 
mated, the  work  of  removal  may  he  completed,  and  finally  the  walls 
of  the  abscess  will  be  collapsed,  join  together,  and  become  united 
by  adhesion,  thus  completing  the  process  of  resolution.     But  the 
work  does  not  always  progress  uniformly.     Oftentimes  the  cause 
of  suppuration  will  recur,  and  for  a  time  pus  may  again  be  dege- 
nerated.    This  may  occur  many  times  before  the  abscess  is  finally 
resolved.  "^ 

In  a  good  majority  of  cases,  perhaps,  the  contents  of  the  chro- 
nic abscess  gradually  finds  its  way  to  the  surface  of  the  body. 
The  process  by  which  thiH  is  done  is  identical  with  that  described 


;  1 

i  . 


110 


PRINCIPLES    OF    SURGERY. 


I  it  £2 


mf<a^»l 


[Mm 


as  the  process  of  pointing  in  acute  abscess.  Through  an  opening 
thus  made  by  nature,  the  pus  will  slowly  discharge,  and,  under 
favorable  circumstances,  the  walls  will  coalesce,  and  unite  by 
adhesion,  or  the  space  fill  up  by  granulation.  In  every  case,  when 
the  pus  is  gradually  removed,  either  by  absorption  or  by  dis- 
charge, the  structures  which  had  been  pressed  aside  will  slowly 
resume  their  natural  position. 

Sinus. — In  some  cases,  after  the  pus  has  discharged,  healing, 
neither  by  union  nor  granulation,  will  take  place,  but  the  abscess 
will  shrink  up,  so  as  to  be  very  small ;  yet  it  will  not  heal.  Lead- 
ing from  where  had  been  the  heart  of  the  abscess  to  the  place 
where  the  exit  of  pus  had  been  made,  is  a  canal,  called  a  sinus. 
The  pyogenic  membrane  which  had  lined  the  abscess  now  lines  this 
canal,  and  is,  perhaps,  possessed  of  a  higher  degree  of  develop- 
ment, and  bears  a  certain  resemblance  to  mucous  membrane,  in  its 
power  to  secrete  and  absorb.     ( Vide  Fistula.) 

Treatment  of  Chronic  Abscess. — The  surgeon  will  not  be  in  a 
hurry  to  open  the  abscess.  The  fact  must  not  be  forgotten  that 
the  contents  may  be  absorbed.  By  making  an  incision,  the  pus 
will  at  once  be  got  rid  of;  but,  unlike  in  the  acute  abscess,  this 
sudden  discharge  is  not  unattended  with  danger.  It  is  an  impor- 
tant practical  fact,  that  very  often,  after  this  quick  escape,  ex- 
haustion of  the  patient's  strength  follows,  with  hectic  symptoms, 
terminating  in  death.  This  serious  result  has  commonly  been 
attributed  to  the  entrance  of  air,  and  such  may  undoubtedly  be 
the  case.  The  pus,  suddenly  escaping,  leaves  a  space  which  will 
be  occupied  by  the  air,  ready  to  rusn  in ;  and  this  air,  in  a  short 
time,  may  so  act  upon  the  matter  as  to  cause  chemical  changes — 
decomposition,  indeed — by  which  the  system  will  become  quickly 
and  seriously  affected.  It  is  not  the  irritation  of  the  air  as  such, 
but  the  rcoult  of  the  changes  which  it  produces  in  the  pus.  Those 
who  have  seen  chronic  abscesses  treated  by  incision  and  by  imme- 
diate pressing  out  of  the  pus,  and  perhaps  thereafter  closing  of 
the  wound,  will  have  noticed  that  in  a  few  days,  when  a  second 
discharge  took  place,  the  pus  had  become  much  more  offensive 
than  at  the  first. 

This  great  danger,  then,  which  follows  such  treatment,  will  lead 
the  surgeon  diligently  to  consider  whether  a  safer  course  cannot 


v- 1 

ux;   uuisucu. 


• J 


ha    nliuni-linil    llTwIor 


CHRONIC    ABSCESS. 


Ill 


certain  circumstances,  to  attain  tLat,  attention  will  be  directed. 
This  is  a  safer  procedure,  but  it  is  a  tedious  one,  and  will  not 
necessarily  be  adopted  in  every  case.  If  the  abscess  is  super- 
ficial— that  is,  has  arisen  in  a  superficial  tissue— or  if  an  impor- 
tant organ  is  not  involved,  the  quicker  course  may  safely  be 
pursued. 

It  may  not  be  impossible  to  remove  a  portion  of  the  contents  of 
the  abscess  in  the  manner  recommended  by  Abernethy,  by  which 
the  entrance  of  air  is  prevented ;  but  there  is,  as  a  general  thing, 
a  new  supply  of  pus  in  a  short  time,  unless  the  cause  of  its  forma- 
tion  be  removed.     I   have   enjoyed  the  opportunity  of  seeing 
treated,  and  of  treating,  a  large  number  of  chronic  abscesses. 
Among  those  I  have  treated  were  some  of  the  abdomen,  of  the 
pelvis,  and  the  psoas  abscess.    The  course  of  treatment  I  adopted 
was  as  follows :  The  abscess  having  approached  near  to  the  sur- 
face, I  made  a  direct  opening  into  its  cavity.     The  incision  was 
not  large,  nor  yet  small ;  it  was  just  large  enough  to  allow  the 
escape  of  as  much  pus  as  would  relieve  the  pressure  due  to  the 
accumulating  matter.     Care  was  taken  to  allow  only  so  much  to 
escape  as  the  tissues  would  force  out.    It  will  be  remembered  that 
the  structures  have  been  pushed  aside  by  the  abscess.     In  these 
structures  there  is  naturally  a  tendency  to  return  to  their  natural 
position.    Now,  if  the  pressure  cease,  this  return  may  be  expected 
to  take  place  ;  and  not  only  that,  but  they  will  gradually  press  out 
the  pus,  if  it  have  a  way  to  escape.     Hence  the  propriety  of  the 
treatment.     An  opening  is  made,  which  must  not  be  allowed  to 
close ;  yet  no  tent  should  be  introduced.     Squeezing  out  of  the 
pus  is  strictly  avoided,  and  the  tissues  are  allowed  to  regain  their 
natural  relationship,  by  which  the  pus  is  expelled,  and  the  walls  of 
the  abscess  gradually  approximated.    Before  making  the  incision, 
the  patient  was  placed  in  a  natural  position ;  because,  after  the 
opening  is  made,  a  chai^ge  in  the  position  of  the  body  would 
force  out  the  matter  sooner  than  the  tissues  could  regain  their 
original  place,  and  consequently  the  entrance  of  air  would  neces- 
sarily follow.      A  poultice  was  always  applied  at  once,   which 
soothed  the  part,  and  also  tended  to  keep  open  the  wound.    Within 
twelve  hours,  if  the  wound  had  closed,  it  was  gently  parted  by  the 
probe.     This  course  of  treatment  I  can  confidently  recommend  to 

thfl    aff.nnfinn    r\f    tVin    w\%,r^C^a^: --■ ... 


'^niiiuii  3  nioiuoa  01  opeiiiiiff.) 


t 


i 


112 


PRINCIPLES    OF    SURGERY. 


U'l'i  (ft 


i^ 


I'.i: 


K 


;jlDfif 


But  I  would  not  recommend  it  to  be  practised  to  the  exclusion  of 
that  based  on  the  fact  that  pus  may  be  gradually  removed  by  the 
absorbents,  and  that  to  secure  the  possibility  of  such  taking  place, 
the  part  should  constantly  be  in  a  state  of  rest— enpy  freedom 
from  disturbance,  mechanical  and  physiological.  (Hilton.)  But 
when  it  is  seen  that  a  cure  by  absorption  will  not  be  accom- 
plished, then  an  opening  ought  to  be  made  in  the  most  depending 
position,  either  with  a  knife,  or  as  recommended  by  Hilton. 

Sinus,  or  Fistula. — By  this  is  understood  an  abnormal  channel 
in  the  tissues,  with  an  opening  at  one  or  at  both  extremities,  and 
lined  by  a  pseudo-membrane  similar  to  that  which  lines  the  cavity 
of  a  chronic  abscess.  It  has  elsewhere  been  explained  that  a 
sinus  may  result  from  an  abscess ;  it  is,  indeed,  the  most  common 
way  in  which  it  forms.  It  may,  however,  be  due  to  other  causes. 
Sometimes  the  duct  of  a  secreting  gland  becomes  occluded,  and 
the  secretion,  having  collected,  will  after  a  time  seek  another 
channel,  which  will  be  made  through  the  agency  of  inflammatory 
action.  In  due  time,  the  canal  made  will  be  lined  by  a  false  mem- 
brane, secreting  pus.  The  fluid,  continually  flowing  along  this 
abnormal  passage,  is  a  source  of  irritation,  and  hence  the  con- 
tinued formation  of  pus.  Again :  in  the  rectum,  ulceration  some- 
times takes  place  through  its  coats,  and  through  this  the  faeces 
make  their  way  into  the  tissue  without  the  rectal  wall.  Inflamma- 
tion results ;  the  pus  and  ffcces  burrow  into  the  deeper  structures, 
and  often  downward  along  the  course  of  the  rectum,  and  finally  to 
the  surface  of  the  nates.  The  matter  having  been  discharged,  there 
remains  a  sinus,  or  two  or  more  sinuses,  lined  by  a  false  membrane. 
The  ffeces  continuing  to  pass  into  and  through  the  new  channels, 
there  is  continued  irritation  at  each  act  of  defecation.  The  parts, 
therefore,  cannot  heal ;  but  pus  is  steadily  elaborated.  Again,  a 
fistula  may  result  from  a  penetrating  wound,  which,  because  of 
motion,  cannot  heal ;  or  because  a  foreign  body  is  lodged  at  the 
bottom  of  the  wound,  and  which  precludes  the  possibility  of  heal- 
ing taking  place. 

These  sinuses  may  continue  for  an  indefinite  period  of  time, 
simply  because  the  irritation  continues. 

Treatment.— Thoy  were  formerly,  and  I  fear  arc  even  yet  by 
some,  treated   almost   invariably  by  stimulating  injections,  the 


Oiycct  Ui    tVUlCu  Tvas  to  Clcatc  a,  luGTQ  itcaivn 


loa. 


n^i«/»fiim   nt 


CHRONIC    ABSCESS. 


113 


iodine  has  been  a  favorite  injection.  It  was  generally  deemed 
necessary  to  destroy  the  false  membrane,  and  sometimes  a  quicker 
method  than  the  above  was  adopted.  To  do  the  quick  work,  a 
piece  of  caustic  was  thrust  in  and  brought  in  contact  with  every 
part  of  the  false  membrane.  The  false  membrane  being  thus 
destroyed,  it  was  hoped  that  healing  by  granulation  would  follow. 
Sometimes  a  seton,  or  a  piece  of  lint,  was  introduced  for  the  same 
purpose.  When  these  means  failed,  a  director  was  introduced, 
when  possible,  along  the  track,  and  a  bistoury,  probe-pointed' 
made  to  follow  it,  and  then  divide  the  tissue  intervening  between 
the  sinus  and  the  surface.  Of  all  the  foregoing  methods  of  treat- 
ment, the  last  is  the  only  one  that  can  be  recommended.  The 
others  are  worse  than  useless.  We  have  before  learned  that  if  the 
surfaces  of  an  emptied  abscess  be  brought  together  and  retained 
so  without  motion,  they  will  unite  together  as  do  the  surfaces  of  a 
wound.  It  will  be  the  same  with  the  walls  of  a  sinus :  if  held 
immovably  together,  they  will  also  unite.  The  lymph  which  had 
degenerated  into  pus  heretofore,  will  constitute  a  bond  of  union, 
by  which  the  healing  will  be  accomplished.  It  will  be  understood' 
then,  that  the  false  membrane  ought  not  to  be  destroyed ;  that  it 
is,  indeed,  useful,  inasmuch  as  speedy  healing  may  take  place  by 
adhesion  of  the  walls.  The  treatment,  therefore,  consists  in 
removing  every  cause  of  irritation,  and  thereafter  maintaining  the 
parts  in  a  state  of  perfect  quietude. 

Motion,  either  incessant  or  periodical,  may  be  the  only  cause  of 
the  irritation. 

How  can  the  parts  then  be  kept  at  rest  ?  In  some  cases  it  is 
almost  or  quite  impossible  to  do  so ;  and  the  only  way,  as  in  fistula 
in  ano,  is  to  divide  the  muscle.  In  the  case  of  the  fistula  in  ano, 
every  time  the  bowels  are  moved,  the  sinus  is  disturbed  by  the 
action  of  the  sphincter  ani,  and,  as  the  action  of  this  muscle  can- 
not  be  arrested,  the  only  course  to  pursue  is  to  divide  it,  after 
which  the  sinus  may  be  expected  to  heal  by  granulation.  But  in 
other  parts  of  the  body  a  fistulous  track  may  be  so  kept  at  rest 
as  to  allow  union  to  take  place ;  to  secure  this  the  best  efforts 
must  be  made,  and  this  may  more  frequently  be  done  than  is 
generally  supposed.  To  elucidate  this  subject  and  impress  it  with 
high  authority,  I  must  refer  to  the  interesting  and  important  cases 

rCDOrted  hv  Tlilfnn         TTo  anaaha  r.P  „K„«-.„« ]  _: • • 

i       ,. — -  ..^-..ta,-^  VI  aucucsscB  aiiu  SiUUSVS  lU  variouB 


8 


i 

'4 


Wl  q 

'•i! 


Ill 


114 


PRINCIPLES    OF    SURaERY. 


parts  of  tbe  body,  as  the  occipital  region,  the  cervical,  under  the 
platysma  myoidea,  and  under  the  sterno-cleido-mastoideus,  in  the 
^  groin,  popliteal  region,  &c.,  where  a'  cure  was  effected  by  simple 
attention  to  rest,  preventing  motion  in  the  part. 

At  the  time  I  read  the  lectures  in  the  "  Lancet,"  I  had  under 
my  care  a  patient,  a  German,  whose  case  seemed  a  suitable  one 
upon  which  to  test  the  principles.  When  he  first  consulted  me  I 
was  informed  by  him  that  he  had  "scrofula,"  and  that  he  had 
been  under  the  treatment  of  several  surgeons,  who  had  tried  a 
variety  of  remedies  in  vain.  I  found  the  opening  of  a  sinus  near 
the  angle  of  the  jaw  on  the  right  side.  The  probe  could  be  made 
to  pass  readily  beneath  the  integument  up  nearly  to  the  ear,  and 
also  deeply  backward  under  the  sterno-mastoid  muscle.  For  the 
space  of  an  inch  around  the  orifice  there  was  the  livid  appearance 
characteristic  of  such  sores.  His  constitution  was  in  every  way 
sound,  there  being  no  indications  of  scrofulous  disease,  and  I  con- 
cluded that  the  cause  of  the  continued  discharge  must  be  sought 
in  the  part.  I  could  scarcely  believe  that  the  motion  consequent 
upon  eating  was  sufficient  to  maintain  the  disease,  and  therefore 
looked  for  something  else ;  and  I  had  not  to  look  far.  Frequently 
meeting  him  in  the  street  I  had  noticed  that  he  invariably  held  a 
cigar  in  his  mouth,  and  seemingly  with  great  firmness,  so  as  to 
create  an  appearance  of  tenseness  in  the  region  of  the  sore.  He 
admitted  that  he  almost  always,  when  awake,  had  a  cigar  in  his 
mouth.  I  at  once  decided  in  my  own  mind  that  here  was  the 
cause  of  the  trouble.  Having  explained  to  him  my  opinion  as  to 
the  cause  of  the  continued  annoyance,  he  promised  thereafter  to 
confine  himself  to  at  least  periodical  smokes.  I  at  the  same  time 
applied  adhesive  strips  around  the  part,  for  the  purpose  of  fixing 
the  muscles  and  fascia.  In  a  few  weeks  there  was  decided  im- 
provement. The  discharge  was  less  than  it  had  been  for  years. 
Subsequently  I  thought  that  if  collodion  were  freely  applied 
around  the  part,  so  as  to  fix  the  tissue  more  firmly,  and  press 
together  the  walls  of  the  sinus,  the  result  might  prove  beneficial. 
This  treatment  proved  very  successful,  and,  although  he  could  not 
or  would  not  refrain  from  smoking,  as  I  had  urged,  nevertheless, 
in  a  few  months  the  sinus  had  quite  healed. 

When  a  sinus  cannot  be  retained  in  a  state  of  rest  by  pressure, 

/M'    Kv  pnlln/linn      tViovo    aanmn    fn    nn    nn    n.lt:f>rtin.t.ivfi  •    thfl   hiat.Olirv 


PYEMIA. 


115 


must  be  used,  and  the  parts  divided.  But  it  must  not  be  forgotten 
that  this  division  of  the  tissues  secures  the  grand  desideratum,  rest, 
and  allows  the  opened  sinus  to  heal  by  granulation.  Could  that 
rest  be  secured  without  the  division,  there  would  be  all  the  differ- 
ence which  exists  between  healing  by  adhesion  and  that  by  gi-anu- 
lation. 


CHAPTER    XIV. 

Pyemia— Causes— Treatment— Softening— Ulceration— Sloughing— Gangrene 

— Treatment. 

Pathologi/.— This  is  a  diseased  condition  of  the  blood,  and  is 
attended  with  profoundly  evil  symptoms,  and  too  often  followed 
by  fatal  results. 

Some  product  of  inflammation  becomes  intimately  admixed  with 
the  blood,  by  which  that  fluid  is  Mterallj  poisoned ;  and  which,  in 
turn,  involves  the  whole  system  in  disease,  often,  as  I  have  said, 
unto  death. 

It  was  formerly  understood  that  pus  was  the  material  which  had 
found  its  way  into  the  volume  of  blood.  But  there  seems  to  be 
some  reasonable  doubt  respecting  this  question.  There  are  only 
two  ways  by  which  pus  could  enter  the  circulating  blood :  by  ab- 
sorption,  or  through  the  veins  when  accidentally  divided ;  or  when 
it  has  formed  within  it.  Respecting  the  first,  we  have  learned  that 
pus-cells  are  too  large  to  be  capable  of  passing  through  the  coats 
of  the  absorbents ;  and  that,  when  purulent  matter  is  removed  by 
absorption,  a  prerequisite  to  its  taking  place  is  the  breaking  down 
of  the  pus-cells.  Moreover,  it  is  a  fact  to  be  remembered,  that 
large  quantities  of  pus  are  often  absorbed  without  any  constitu- 
tional effects  whatever  presenting  themselves,  without  any  sign  of 
pyemia.  The  worn  out,  or  perished  cells,  are  eliminated  without 
any  perceptible  evil.  We  look  here,  then,  in  vain  for  an  explana- 
tion of  the  problem. 

Again,  it  has  been  supposed  that  when  veins  are  divided  there 
is  an  open  way  for  pus  to  enter  the  blood,  should  it  form  in  that 
part ;  lorgetting,  as  a  writer-  has  said,  that  if  such  a  way  were  open 


I ; 

5'! 


-m 


, 

i: 

V- 

1 , 

ft 

1 

1 

m 

Hi 

ft^^i 

: 

uM 

y 

k 

H 

116 


PRINCIPLES    Of    SURGERY. 


■I 
-'  U  i.'f 

i  I'  I 


for  pus  to  enter,  by  the  same  way  blood  would  certainly  escape ; 
yet,  in  cases  of  pyemia  occurring  in  connection  with  wounds,  there 
is  no  sign  of  hemorrhage.  Probably  the  fact  that  pyemia  very 
frequently  follows  phlebitis,  has  led  to  the  conception  that  pus  has 
directly  entered  the  circulation.  But  the  objection  referred  to 
seems  to  be  fatal  to  the  theory.  But  may  not  pus  be  formed  in 
connection  with  inflammation  around  the  coats  of  a  vein,  in  con- 
sequence of  which  a  separation  of  fibrin  from  the  blood  takes  place 
within  the  vein  ?  Here,  again,  actual  observation  has  shown  that 
such  is  very  unlikely  to  occur. 

The  primary  effect  of  the  inflammation  is  the  formation  of  a 
clot  of  fibrin  around  the  vessel  and  within  it ;  and  when  inflamma- 
tion extends  and  suppuration  ensues,  even  within  the  vein,  it  will 
be  found  that  the  clot  extends  along  its  course,  so  that  a  barrier 
of  clotted  fibrin  always  exists  to  prevent  the  entrance  of  pus  into 
the  blood.  Likewise,  when  a  vein  has  been  divided,  the  clot  will 
close  up  the  wound,  and  very  likely  occlude  the  vessel  to  a  greater 
or  less  extent.  The  formation  of  these  clots  in  inflammation  does 
not  seem  to  be  due  entirely  to  the  inflammatory  action.  To  beget 
this  disease  there  seems  to  be  some  peculiar  condition  of  the  blood, 
or  its  fibrin,  which  renders  it  easy  of  coagulation.  There  is  a 
deficiency  of  vitality,  which  is  manifested  by  a  speedy  coagulation ; 
and,  subsequently,  an  equally  speedy  disintegration  of  its  sub- 
stance. And  here  seems  to  be  the  most  plausible  explanation  of 
the  disease.  Here  is  its  pathology.  The  clot  does  not  disintegrate 
in  a  body ;  but  its  boundaries,  which  are  constantly  washed  by  the 
venous  current,  break  away  particle  after  particle,  until  the  whole 
mass  is  floating  in  the  circulating  blood  in  the  form  of  minute 
particles  of  dead  matter,  which  may  continue  to  undergo  decom- 
position. It  is  this  material,  thus  introduced  into  the  blood,  which 
affects  so  disastrously  the  vital  fluid,  which  acts  as  a  rank  animal 
poison  to  it  and  the  whole  system.  Thus  it  will  be  seen  that 
pyemia  is  not  due  to  the  admixture  of  pus,  but  to  a  more  noxious 
agent ;  that,  while  it  is  derived  from  the  fibrin,  yet  it  is  not  a  de- 
generation of  that  substance  into  pus,  but  an  actual  death  and  dis- 
integration. Perhaps  it  is  not  in  every  case  an  actual  death;  but 
at  least  it  is  a  degeneration  far  more  degrading  than  that  of  pus. 
Virchow  says,  "It  is  a  puriform,  but  not  a  purulent  substance." 


PYEMIA. 


117 


Causes  of  pyemia  may  be  divided  into  predisposing,  and  local, 
or  exciting. 

Among  the  predisposing  causes  are  other  diseases  of  the  blood, 
such  as  prostration  from  organic  diseases,  as  in  lung  and  kidney 
affections,  diseases  of  joints,  exhaustion  from  surgical  complaints, 
accidents,  amputations,  shocks,  parturition,  unhealthy  occupation, 
and  over-indulgence  in  food.  ^ 

Local  causes  most  frequently  are  some  injury,  by  which  the  vein 
tissue  is  much  involved ;  severe  lacerating  wounds,  of  the  leg  par- 
ticularly.  Anything,  indeed,  which  causes  inflammation  of  the 
veins.     It  is  a  common  sequence  of  gunshot  wounds. 

During  the  progress  of  the  American  war,  pyemia  has  been  of 
very  frequent  occurrence.     Whilst  sojourning  in  the  Army  of  the 
Potomac,  after  the  battle  of  Chancellorsville,  and  afterward  in  the 
Lincoln  Hospital,  at  Washington,  I  had  the  opportunity  of  wit- 
nessing  the  course  of  not  a  few  cases.     No  doubt  camp  life,  espe- 
cially to  the  recently  made  soldiers,  and  the  excitement  as  well  as 
the  toil  of  forced  marches  and  of  battle,  constitute  very  potent 
predisposing  causes  of  the  disease.   And  very  active  exciting  causes 
of  the  malady  I  conceived  to  be,  from  careful  observation,  the 
protracted,  painful,  and  often  ruthless  examinations  made,  to  find 
balls,  which  were  supposed  or  known  to  be  imbedded  in  the  tis- 
sues, and  the  injudicious  efforts  made  to  recover  them.    Examina- 
tion by  the  finger  was  unhesitatingly  resorted  to  and  continued 
for  some  time.     As  a  result  of  this  there  could  not  be  otherwise 
than  laceration  of  tissue,  a  breaking  up  of  fibrinous  adhesions, 
which  nature  had  made  in  her  anxious  efforts  to  heal,  and  which 
then  would  speedily  degenerate  or  die,  thereby  producing  the  ma- 
terial which  we  have  seen  leads  to  the  disease.     I  could  account 
in  no  other  way  for  the  fact  that  patients  who  had  been  placed  on 
the  operating  table  with  no  single  unfavorable  symptom  "  for  ex- 
amination," and  who  had  been  subjected  to  a  long-continued  and 
extensive  examination,  terminating  sometimes  in  the  abstraction 
of  a  ball,  often  without  discovering  it,  would  the  same  evening 
have  a  chill,  and  two  days  after  have  all  the  symptoms  of  pyemia, 
and  upon  the  third  or  fourth  day  would  die.     I  was  convinced,  in 
my  own  mind,  that  it  would  be  better  for  the  patient  were  the  ball 
never  searched  for,  unless  in  cases  of  comminution  of  bone. 
Resulting  from  this  blood-poison  may  be  expected,  in  most 


118 


PRINCIPLES    OF    SUnaERY. 


cases,  secondary  deposits  in  the  capillary  structure.  The  detritus 
of  the  clot  which  has  become  mixed  with  the  blood,  will  fail  to 
pass  through  these  small  vessels,  but,  becoming  lodged  will  set  up 
a  low  form  of  inflammation,  followed  by  the  fornjiation  of  numer- 
ous small  abscesses.  It  is,  of  course,  in  the  venous  blood  that  the 
morbid  material  first  floats  when  it  leaves  the  site  where  the  clot 
had  formed.  It  therefore  passes  immediately  to  the  heart,  and 
thence  into  the  lungs.  Here,  then,  are  the  first  capillaries  through 
which  the  debris  attempt  to  pass;  and  it  is  here  where  the 
secondary  deposits  by  far  the  most  frequently  occur.  Having 
passed  through  the  lungs,  the  next  structures  in  frequency  to 
become  the  site  of  deposit  are  the  brain,  liver,  kidneys,  and 
joints.  (Syst.  Surgery.)  In  connection  with  the  secondary  de- 
posits, or  arising  therefrom,  will  be  seen  an  asthenic  action  in  the 
whole  capillary  structure  of  the  body,  characterized  by  an  oedema- 
tous  condition.  I  have  observed  this  more  particularly  in  the 
lower  e;ctremities,  which  resemble  anasarca,  only  that  there  is  less 
pitting  on  pressure.  It  would  seem  that  the  coats  of  the  minute 
vessels  lose  their  tone,  and  consequently  exudation  of  serum  and 
fibrin  is  favored,  into  the  cellular  structure. 

Symptoms  and  Diagnosis. — Symptoms  of  pyemia  are,  as  a  gen- 
eral thing,  well  marked;  consequently,  the  diagnosis  is  never 
difficult.  The  history  of  the  disease  is  important  to  assist  in  the 
diagnosis,  inasmuch  as  the  disease  comes  on  after  some  injury  or 
operation. 

If  a  wound  is  suppurating,  it  will  be  seen,  as  the  disease  is 
established,  to  cease  discharging,  and  to  become  dry.  Soon  there- 
after, the  skin  and  the  secretory  organs  generally  will  cease  to 
act ;  but  afterwards  there  will  be  a  clammy  moisture  of  the  skin, 
and  diarrhoea  may  set  in.  The  disease  is  ushered  in  by  a  chill, 
which  will  be  repeated  from  time  to  time.  The  pulse  will  be  quick 
and  uncertain,  and  compressible.  The  tongue  will  have  a  typhoid 
appearance ;  indeed,  many  of  the  symptoms  are  the  same  as  cha- 
racterize typhoid  fever.  In  addition  to  these  symptoms,  others 
may  present  themselves,  depending  upon  circumstances  peculiar 
to  the  case. 

Treatment. — The  local  treatment  will  consist  in  the  application 
of  warm  fomentations,  or  poultices,  with  the  view  of  re-establish- 
iner  the  discharee  and  preventiner.  at  least  of  limitins.  the  entrance 


PYEMIA. 


119 


of  the  poison  into  the  circulation.  When  the  secondary  deposits 
give  rise  to  local  inflammation,  the  treatment  will  be  on  general 
principles.  , 

The  constitutional  treatment  will  be  directed  to  the  elimination 
of  the  blood-poison,  and  to  sustaining  the  strength,  which  will 
rapidly  decline.  The  skin,  kidneys,  and  bowels  should,  as  far  as 
possible,  be  kept  in  a  healthy  state  of  action.  Medicines  cannot 
be  found  which  possess  any  specific  power  to  neutralize  the  poison. 
Such  only  should  be  given  as  will  tend  to  aid  in  the  elimination  of 
the  morbid  material,  or  give  tone  and  strength  to  the  stomach, 
that  nourishment  may  be  advantageously  administered.  Stimu- 
lants ought  from  the  first  to  be  freely  and  frequently  given. 
Everything,  indeed,  will  depend  upon  the  ability  of  the  stomach 
to  bear  nutritious  food  and  drinks,  as  well  as  judiciously  admin- 
istered stimulants. 

Pathology — Softening. — We  have  elsewhere  seen  that  softening 
of  tissue,  in  connection  with  inflammation,  is  one  of  the  many 
eflForts  constantly  made  to  cure,  at  every  step  of  the  inflammatory 
process.  This  is  more  particularly  seen  in  connection  with  the 
formation  and  pointing  of  an  abscess.  This  softening  has  been 
likened  to  that  which  accompanies  or  precedes  parturition,  by 
which  the  soft  parts  are  prepared  for  the  transit  of  the  child  into 
the  world.  And  certainly  the  two  processes  are  much  alike, 
nature  seeming  to  be  adequate  for  the  requirements  of  both  cases. 
In  parturition,  the  more  complete  the  softening — the  relaxation — 
the  more  speedy  the  labor,  and  the  less  suffering.  Likewise  in 
inflammation :  when  there  is  softening  and  yielding,  and  therefore 
swelling,  the  pain  is  less,  and  the  danger  diminished.  So  far, 
softening  may  be  regarded  as  a  physiological  action ;  but  in  many 
cases  it  becomes  a  disease.  The  softening  may  be  too  great,  and 
more  extensive  than  is  requisite  to  subdue  the  inflammation.  This 
may  arise  from  a  previously  dilated  or  weak  condition  of  the  part, 
or  of  the  whole  system.  Improper  treatment  is  not  unfrequently 
the  cause  of  undue  softening.  Position,  or  any  application  that 
induces  passive  congestion,  may  become  a  cause  of  softening.  I 
have  in  a  great  many  instances  seen  long-continued  poulticing, 
and  other  relaxing  applications,  lead  to  disastrous  softening.  Cer- 
tain tissues  are  more  subject  to  softening  than  others:  as  the 
brain ;  spinal  cord ;  bone  ;  synovial  membranej  &c= 


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120 


PRINCIPLES    OP    SURGBET. 


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Results. — Degeneration  will  inevitably  result  from  softening 
{vide  Diseases  of  Joints),  ^and  the  tissue  will  often  become  much 
thickened.  Again,  ulceration  is  a  frequent  sequel.  These,  then, 
are  the  results  of  softening :  degeneration,  thickening,  ulceration, 
also  absorption;  besides,  the  system  may  become  affected,  leading 
to  exhaustion  and  death. 

Treatment  of  pathological  softening  will  consist,  mainly,  in  re- 
moving the  cause ;  to  do  which,  a  distinct  knowledge  of  the  patho- 
logy will  be  essential.  Relaxing  applications  must  be  discontinued, 
and  everything  which  may  induce  passive  congestion  or  pressure 
must  be  removed.  The  constitution  will  be  treated  according  to 
circumstances. 

Ulceration  is  akin  to  softening,  or  may  be  considered  a  further 
step  in  the  same  pathological  changes.  It  is  desirable  to  have  a 
distinct  meaning  attached  to  the  term  ulceration.  Some  confusion 
I  have  found  to  exist,  in  consequence  of  the  term  "ulcer"  being 
employed  synonymously,  when  its  proper  use  is  in  connection  with 
quite  a  different  thing,  although  the  two  may  coexist.  An  ulcer, 
it  may  be  stated  here,  is  a  sore — a  solution  of  continuity  upon  a 
surface,  which  nature  is  attempting,  successfully  or  otherwise,  to 
heal.  If  the  effort  is  successful,  it  is  a  simple  ulcer;  if  unsuc- 
cessful, it  becomes  an  unhealthy  ulcer.  But  ulceration  is  always 
a  pathological  action:  it  signifies  destruction — actual  death  of 
tissue ;  only,  that  instead  of  a  large  portion,  a  perceptible  quan- 
tity, perishing,  it  is  by  particles.  Molecule  after  molecule 
softens,  dies,  and  is  steadily  carried  away  by  the  absorbents,  and 
eliminated  from  the  system.  In  health,  there  is  a  balance  main- 
tained between  decay  and  the  building  up  of  tissue ;  if,  however, 
the  decay  is  greater  than  the  repair,  then  there  is  an  >  xcess  of 
molecular  death,  and  there  will  be  a  diminishing  of  tte  ?issr:e. 
Sometimes  this  occurs  in  a  whole  organ,  and  constitutes  s:trop'iy. 
When  it  takes  place  in  a  part,  it  is  ulceration.  Like  softening,  it 
often  comes  under  the  surgeon's  notice  as  a  curative  operation. 
( Vide  Pointing  of  Abscess.) 

Ulceration  is  sometimes  rapi  If  the  tissue  be  predisposed  in 
consequence  of  natural  weakneta,  or  from  an  injury,  by  which  its 
vitality  ia  iri:v;aircd,  molecular  death  will  more  readily  and  quickly 
follow  any  exciting  cause.     Again,  the  application  of  a  poison 


PYEMIA. 


121 


may  hasten  molecular  death;  also,  when  it  has  entered  the  system, 
it  may  constitute  a  predisposing  cause. 

The  causes,  then,  are  predisposing  and  exciting,  both  of  which 
may  act  together. 

The  treatment  of  ulceration  is  obvious.  Ascertain  the  cause, 
and  remove  it ;  or  if  that  be  impossible,  endeavor  to  lessen  the 
effects.  When  the  process  of  ulceration  has  been  stayed,  healing 
ought  to  supervene ;  but  very  generally  the  system— the  blood— 
;s  impaired,  and  disqualified  for  supplying  proper  reparative  ma- 
terif.1.  Attention  will  therefore  be  directed  to  the  general  health, 
as  well  as  to  protecting  the  part  where  destruction  has  taken 
place. 

BougJnng.— Closely  allied  to  the  ulcerative  process,  is  slough- 
ing. In  this,  however,  the  destruction  of  tissue  is  more  rapid  and 
extensive.  It  perishes,  not  by  atoms  simply,  but  in  larger  por- 
tions, though  not  in  a  mass,  as  in  gangrene.  Sloughing  is  often 
seen  to  follow  a  severe  bruise.  A  crushing  force  has  mechanically 
disturbed  the  physical  substance,  and  the  vitality  of  every  atom  is 
quite,  or  almost,  crushed  out,  the  coats  of  the  vessels  no  longer 
possessing  the  power  to  discharge  their  functions.  The  blood 
passing  to  the  part  does  not  permeate  it,  although  it  gives  to  it  a 
quantity  of  the  watery  element.  There  is  but  the  faintest  resem- 
blance between  this  process  and  that  of  inflammation ;  it  is  this 
which  alone  distinguishes  sloughing  from  gangrene. 

Sloughing  may  also  be  caused  by  some  violent  poison :  as,  for 
instance,  when  syphilitic  poison  of  a  virulent  kind  comes  in  con- 
tact with  the  glans  penis.  Its  effects  are  often  immediate,  like  a 
corrosive  poison,  before  absorption  can  possibly  have  taken  place. 
Any  one  who  has  walked  a  syphilitic  ward  will  have  seen  instances 
where  in  a  short  time  the  whole  of  the  glans,  and  even  more  of 
the  organ,  has  sloughed  away.  No  doubt,  absorption  begins  to 
take  place ;  but  the  vessels,  in  the  very  act,  receive  their  death- 
poison.  Continued  pressure,  with  undue  heat,  especially  in  a 
constitution  weakened  with  disease,  often  causes  sloughing,  as  well 
as  gangrene.  Instances  are  to  be  seen  in  the  form  of  bed-sores, 
where  the  patient  has  been  confined  to  bed  for  some  time— more 
particularly  from  exhausting  fevers,  or  other  like  affections.  In 
every  case,  when  the  system  is  below  par  the  effect  of  the  exciting 
cause  will  be  greater. 


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ti 


122 


PRINCIPLES    OP    SURGERY. 


The  sloughing  process  endangers  the  whole  system.  The  dying 
tissue  and  juices  therein,  if  taken  up  by  the  absorbents,  cannot 
but  produce  evil  effects  upon  the  constitution ;  and  the  more  ex- 
tensive the  local  disorganization,  the  greater  will  be  the  probability 
of  general  complication.  * 

Treatment  of  Sloughs. — Will  necessarily  depend  upon  the  cause 
and  the  amount.  When  due  to  an  injury,  and  the  system  is 
healthy,  but  little  is  required  to  be  done.  {Vide  Contusions.) 
When,  however,  the  sloughing  results  from  a  poison,  treatment  of 
the  most  active  kind  must  be  adopted ;  in  most  cases,  the  surgeon 
must  act  promptly — almost  heroically.  The  diseased  tissue  (that 
in  which  the  poison  is  lodged)  must  be  separated  from  the  sound 
as  quickly  as  possible,  so  as  to  limit  the  destructive  process.  The 
most  certain  way  is  to  freely  apply  a  caustic  to  the  part  in  which 
the  virulent  poison  is  so  speedily  destroying  the  vitality.  By 
destroying  this  tissue,  the  poison  may  also  be  destroyed,  or  ren- 
dered impotent  for  further  evil.  While  the  poison  is  yet  upon  the 
surface  of  a  tissue,  this  is  a  sure  as  well  as  a  quick  way  of  staying 
the  disease.  In  a  manner  almost  similar,  the  poison  of  gonorrhoea 
may  be  destroyed  before  it  has  actually  caused  the  inflammation, 
by  applying  a  solution  of  nitrate  of  silver;  also  the  poison  of 
dissection.  In  urgent  cases,  nitric  acid  will  be  needed.  Its  action 
is  prompt,  and  I  have  often  seen  it  applied  with  advantage  to  slough- 
ing tissue.  It  destroys  the  substance,  and  the  poisonous  action  is 
arrested.  Bearing  in  mind  the  object  to  be  secured,  it  will  be  un- 
derstood that  every  bit  of  the  tissue  involved  must  be  reached  by 
the  caustic,  and  that  it  will  be  better  to  destroy  too  much  than  too 
little.  Occasionally,  even  a  largo  amount  of  substance  will  have 
to  be  sacrificed ;  but  when  the  exigencies  of  the  case  demand  it, 
there  can  bo  no  hesitation :  it  is  destroying  a  part  to  save  more — 
perhaps  life  itself. 

When  the  constitution  was  primarily  involved,  or  has  become  so 
as  a  coi.sequence  of  the  sloughing,  stimulants  will  be  demanded  to 
bring  the  system  up  to  par ;  and  then  tonics  and  generous  diet,  to 
retain  it  in  that  condition. 

■  This  supporting  treatment  will  be  particularly  demanded  when 
the  surgeon  has  to  treat  bed-sores;  while  locally,  some  disinfectant, 
as  a  charcoal  poultice,  will  prove  useful. 

(gangrene. — This  is  death  of  tissue  in  substantial  portions,  not 


PYEMIA. 


123 


in  molecules,  not  in  sloughs,  but  in  masses ;  by  it  a  member  of  the 
body,  as  a  toe,  or  a  hand,  or  a  leg,  may  at  once  die. 

Causes. — There  are  predisposing  and  exciting  causes.  Now 
there  is  no  difficulty  m  understanding  that  if  the  feeding  vessel  to 
a  part  be  divided  or  occluded,  so  that  the  part  is  no  longer  sup- 
plied with  blood,  and  heat  no  longer  is  generated,  that  it  must 
inevitably  perish.  But  this  cause  of  gangrene  is  not  always  so 
quick  in  its  effects,  nor  so  perceptible. 

The  predisposing  causes  may  be  given  as  follows :  1st.  A  want 
of  due  nervous  power,  either  in  the  whole  system  or  in  the  part 
affected.  2d.  A  continued  want  of  blood,  such  as  is  supplied  in 
health,  from  which  the  tissue  is  weakened.  3d.  When  the  blood 
is  defective  in  quality.  4th.  Long-continued  congestion  of  a  part 
may  so  derange  the  structure  as  to  render  it  liable  to  mortifica- 
tion. 5th.  Certain  articles,  when  taken  into  the  system,  will  favor 
or  actually  produce  gangrene ;  the  most  notable  of  these  is  ergot 
of  rye.     6th.  Old  age. 

Direct  Causes.— lat.  A  very  common  one  is  the  formation  of  a 
clot  of  fibrin  in  the  heart  or  elsewhere,  which,  being  dislodged,  is 
carried  along  in  the  arterial  stream  until  a  point  is  reached  beyond 
which  the  clot  is  too  large  to  pass ;  and  it  there  effectually  closes 
the  tube  and  cuts  off  the  supply  of  blood.  2d.  In  a  similar  man- 
ner gangrene  is  sometimes  caused  by  the  ligation  of  an  artery. 
In  these  cases  of  sudden  occlusion  the  danger  is  great,  if  collateral 
circulation,  which  is  essential  to  preserve  the  limb,  cannot  be  im- 
mediately established.  3d.  A  growing  tumor,  by  pressing  against 
the  artery,  may  arrest  the  flow  of  blood  therein.  In  this  way 
internal  necrosis  of  bono  is  sometimes  produced  by  even  a  small 
tumor  pressing  against  the  nutritious  vessel  as  it  is  entering  the 
foramen.  4th.  Frostbite  is  a  common  cause  of  gangrene;  the 
intense  cold  destroying  the  vitality  beyond  recovery.  Under  the 
influence  of  the  cold  the  blood  ceases  to  enter  the  tissue.  ( Vide^ 
Frostbites.)     5th.  Intense  heat  in  the  form  of  burns  or  scalds. 

The  terms  moist  and  dry  gangrene,  also  acute  and  chronic,  are 
often  used.  Moist  and  acute  are  the  same,  and  dry  and  chronic 
are  the  same.  In  the  first  the  death  takes  place  quickly,  the  fluids 
still  existing  in  the  part ;  and,  consequently,  the  gangrenous  sub- 
stance is  moist.  When  the  gangrene  takes  place  more  slowly,  the 
fluid  escapes  from  tho  part,  the  bluud  having  ceased  to  flow  some 


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124 


PRINCIPLES    OP    SURGERY. 


I' I'       • 


(■  ' 


lt&    **>     F   I!  II 


f'i'pii 


time  before.  Hence  the  fact  that  gangrene  is  at  once  chronic  and 
dry  or  shrivelled.  The  latter  is  more  frequently  seen  in  the  aged. 
The  terras  idiopathic  and  traumatic  are  also  sometimes  used,  but 
do  not  require  any  special  interpretation. 

Treatment  of  Gangrene. — The  remarks  made  respecting  slough- 
ing will,  in  many  respects,  apply  in  connection  with  the  treatment 
of  gangrene.  The  part  -hich  has  perished  must  of  course  be 
separated  from  the  living  tissue.  To  do  this  nature  always  sets 
promptly  to  work  and  hastens  to  complete  it.  The  process  of 
separation  is  supposed  to  be  accompl,ished  by,  1st,  softening  taking 
place  in  the  tissue  still  living,  and  which  it  may  be  supposed  had 
not  escaped  altogether  that  which  caused  death  in  the  contiguous 
tissue.  The  state  of  gangrene  seems  to  accelerate  the  adjacent 
softening.  2d.  Following  the  softening  is  ulcerative  absorption. 
The  line  of  demarcation  is  gradually  fixed,  and  the  separation  is 
slowly  consummated.  While  some  tissues  are  easily  separated 
under  such  circumstances,  others  are  slow  to  yield  to  the  ulcerative 
process. 

It  is  a  question  of  some  importance  whether,  during  the  process 
of  complete  separation,  any  of  the  dead  substance  is  ever  removed 
by  the  absorbents.  That  such  may  take  place  might  reasonably 
be  inferred  from  the  fact,  that  for  some  time  after  the  other  tissues 
are  quite  divided,  vessels  remain  unsevered  ;  and,  although  blood 
finds  no  tubes  to  traverse  in  the  dead  substance,  the  powers  of 
absorbing  may  continue.  In  this  way  it  is  possible  that  a  thin 
stratum  of  the  gangrenous  substance  may  be  removed.  Yet  it  is 
more  probable  that  the  division  is  made  at  the  expense  of  the 
living  tissue.  When,  therefore,  there  is  an  extensive  surface  of 
gangrenous  substance  in  contact  with  living  tissue,  as  the  greater 
part  of  a  limb,  the  sooner  the  gangrenous  mass  is  separated  the 
less  danger  is  the  system  exposed  to.  On  this  ground  alone  it  will 
be  seen  that  surgical  interference  may  become  necessary.  Although 
nature  earnestly  works  to  rid  the  body  of  the  mass,  she  may  bo 
poisoned  before  the  work  is  consummated. 

But,  in  case  of  a  limb  being  the  seat  of  the  disease,  there  is 
another  reason  for  interference.  In  the  first  place,  as  wo  shall  see 
hereafter,  the  process  of  separation  in  the  bone  is  very  slow ;  and 
finally,  when  it  is  consummated,  the  stump  is  by  no  means  fitted 
fur  uutivu  uurvice.     Tliu  rule,  thurufuru,  ict,  iu  wait  uiilii  uaiuru 


'\ 


VARIETIES    OP    INFLAMMATION. 


1«5 


declares,  in  terms  that  cannot  be  misunderstood,  where  life  still 
remains ;  and  then,  by  the  knife  and  saw,  relieve  her  of  the  weary 
work,  and  at  the  same  time  secure  a  serviceable  stump. 

In  those  cases  where  the  gangrene  is  situated  on  other  parts  of 
the  body  than  a  limb,  and  where  amputation  may  not  be  per- 
formed, a  different  procedure  must  be  adopted.     Much  can  be 
done  to  hasten  the  division  and  removal  of  the  mass,  and  to  pre- 
vent the  entrance,  by  absorption  of  the  poison,  into  the  system. 
Often,  continued  poulticing  will,  by  assisting  the  softening,  and  by 
producing  a  degree  of  inflammation  along  the  boundary  of  the  ter- 
ritory of  the  still  living  tissue,  create  suppuration,  which  will  have 
the  effect  of  establishing  physiological  absorption ;   that  is,  the 
absorption  that  may  take  place  will  be  of  the  living  material 
rather  than  of  the  dead.     By  so  treating  there  will  be  a  greater 
loss  of  structure,  but  it  will  be  attended  with  less  danger  to  the 
constitution,  and  will  be  more  speedily  accomplished.     In  connec- 
tion with  poulticing  there  must  be  the  strictest  attention  to  clean- 
liness, and  disinfectants  should  be  called  into  requisition. 
^  The  constitutional  treatment  will  be  regulated  by  the  rules  spe- 
cified in  treating  of  sloughing,  and  the  remedial  measures  will 
have  to  be  more  assiduously  employed. 


CHAPTER    XV. 

Varieties  of  Inflammation-Phlegmon-Anthrai-Ohilblains-FroBtbites- 

Burns. 

Varieties  of  Inflammation.— Vndcr  this  head  I  intend  to  treat 
of  the  various  forms  of  inflammation  in  which  are  manifested 
phenomena  at  variance  with  those  which  characterize  acute,  or, 
as  I  prefer  to  designate  it,  healthy  inflammation. 

Inflammation  may  be  divided  into  two  great  classes,— the  healthy 
and  the  unhealthy.  Of  the  healthy  I  have  spoken,  and  as  well  of 
Its  products  and  certain  diseases  arising  out  of  inflammation.  It 
18  of  the  unhealthy  I  design  now  to  speak. 

-vuci  uiviB<uus  are  cwiiuuouiy  uiuUe,  as  acute,  subacute,  and 


:-il 


I  r      i ) 


I 


*■  Si 


126 


PRINCIPLES    OP    SURGERY. 


i5 


chronic,  sthenic  and  asthenic,  specific  and  non-specific.  The  acute 
and  sthenic  are  synonymous  terms,  and  may  be  considered  the 
type  of  which  all  the  rest  are  more  or  less  imperfect  copies.  The 
subacute  is  a  condition  intervening  between  the  acute  and  chronic, 
or  sthenic  and  asthenic,  and  scarcely  requires  a  separate  consider- 
ation. Chronic  inflammation  has  been  treated  as  a  disease  arising 
out  of  inflammation.  The  terms  specific  and  non-specific  explain 
themselves.  ( Vide  Acute  Inflammation.) 

The  .individual  diseases  now  to  be  considered  are  phlegmon, 
boils,  and  anthrax,  chilblains,  frostbites,  burns,  hemorrhagic  inflam- 
mation, scorbutic,  scrofulous,  gouty,  rheumatic,  gonorrhoeal,  syphil- 
itic, and  erysipelatous. 

Phlegmon,  or  Phlegmonous  Inflammation. — The  term  implies 
that  the  disease  is  located  in  the  cellular  tissue.  As  a  general 
thing  it  presents  two  distinct  forms,  the  first  of  which  is  the  com- 
mon boil.  A  very  common  cause  of  this  is  a  local  injury,  from 
which  exudation  of  a  plastic  character  has  taken  place  in  the  sub- 
cutaneous cellular  tissue.  This  eff'usion  had  rapidly  coagulated 
with  but  a  futile  attempt  to  organize.  Contraction  attended  the 
coagulation,  and  the  cellular  substance  was  thereby  pressed  upon, 
the  supp'y  of  blood  cut  ofi";  and  all  of  that  involved  was  doomed 
to  death,  in  connection  with  the  adventitious  material.  It  is  this 
gangrenous  cellular  tissue  (for  such  it  is,  although  limited  in  quan- 
tity), and  the  organized  fibrin  in  its  interstices,  which  constitutes 
the  "core"  of  the  boil,  and  which  is  sooner  or  later  expelled  by 
the  process  of  suppuration.  Hence  it  is  that  boils  frequently 
arise  in  a  part  some  time  after  it  has  been  bruised  or  otherwise 
injured.  The  explanation  is  not  difficult.  The  fibrin  being  eff'uscd, 
in  consequence  of  the  injury,  does  not  at  once  produce  irritation 
above  that  due  to  the  injury.  But  after  a  time,  it,  with  the  de- 
stroyed cellular  tissue,  being  a  foreign  body,  creates  inflammation, 
the  object  of  which  is  to  expel  this  foreign  body. 

Boils  are  produced  in  other  ways.  The  occlusion  of  a  duct 
which  opens  upon  the  surface  of  the  body  and  leads  to  a  follicle 
or  gland,  will  result  in  a  collection  of  the  secretion  of  the  small 
gland.  This  material  will  undergo  changes,  and  eventually  become 
a  source  of  irritation  and  inflammation.  Again,  when  morbid 
material  exists,  the  object  of  nature  will  be  to  get  rid  of  the 
0f6igQ  suDotance.     j.acsu  luj,^'  uc  picBcutcu  m  mc  iv-rut  -.-i  ■.— 


VARIETIES    OF    INFLAMMATION. 


127 


pimples,  or  perhaps  quite  large  abscesses,  but  as  a  general  thing 
they  bear  a  close  resemblance  to  the  boil  before  described. 

This  kind  of  boil  is  more  likely  to  occur  when  the  blood  is  in  a 
gross  or  vitiated  state.  Such  a  condition  of  the  blood  may  be 
regarded  as  a  predisposing  cause  of  this  sort  of  boil ;  indeed,  they 
seem  often  to  present  themselves  without  any  other  cause  of  an 
exciting  nature. 

Treatment.—ln  the  first  kind,  it  must  be  remembered  that  a 
process  of  detachment  has  to  take  place  of  the  cellular  tissue,  in 
the  same  way  as  when  a  part  has  become  gangrenous,  and  that 
this  is  to  be  done  by  the  inflammatory  process.  This  may  be 
facilitated  by  poulticing,  and  by  hot  fomentation,  which  will  also 
relieve  the  pain,  which  is  sometimes  very  great.  While  this  "  core  " 
remains  undetached,  there  is  no  use  in  opening  the  little  abscess. 
Probably  it  is  much  better  to  allow  the  boil  to  get  fully  "ripe"— 
that  is,  the  detachment  to  be  fully  completed.  If,  however,  the 
pain  be  severe,  an  early  opening  should  be  made.  So  soon  as' this 
is  accomplished,  and  an  opening  sufficiently  large  is  made,  the 
core  will  extrude,  and  thereafter  the  cavity  will  quickly  heal. 

When  the  boil  is  due  to  the  closing  of  a  small  follicular  duct, 
and  the  blood  is  in  a  gross  state,  there  is  no  reason  for  delay  in 
making  an  opening.  The  blood  must  receive  attention  at  first, 
however,  as  it  is  primarily  at  fault.  It  is  a  common  practice  with 
some,  I  know,  to  give  Epsom  salts  for  a  length  of  time,  under 
such  circumstances,  to  "cleanse  the  blood."  Perhaps  one  or  two 
doses  may  prove  beneficial,  by  preparing  the  blood  for  other  medi- 
cines. Some  preparation  of  iron  should  be  given.  I  much  prefer 
the  tincture,  which  will  give  vitality  and  purity  to  its  composition. 
Other  measures  of  a  general  nature  must  not  be  neglected.  The 
local  treatment  of  this  boil  will  bo  modified  by  the  size  and  stage. 
It  is  always  desirable  to  bring  about  discussion.  They  are,  when 
upon  the  face,  more  an  eyesore  than  painful,  and  this  really  is  the 
only  thing  which  makes  it  necessary  to  refer  to  them.  I  have 
used  often  to  advantage,  as  a  local  application,  tincture  of  iron, 
alone  and  in  conjunction  with  the  extract  of  belladonna.  But 
when  pus  has  actually  formed,  and  seems  to  be  increasing,  and 
very  likely  undermining,  as  it  were,  the  integument— when  there 
does  not  seem  to  be  sthenic  action  enough  to  break  the  skin— then 
i-u  ii.L.,,....n  :;izcai«  vc  made.    i»y  ihiB  proceuure,  tiie  deloriuity  will 


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128 


PRINCIPLES    OF    SURGERY. 


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be  less  than  if  the  opening  were  made  by  nature.  In  some  in- 
stances, a  covering  of  collodion  will  prove  useful. 

AnthraXf  or  Carbuncle. — The  latter  of  the  before-mentioned 
boils  is  sometimes  designated  a  carbuncle :  that  is,  when  the  blood 
is  in  a  state  of  low  vitality ;  and  when  the  boil  is  more  or  less 
flat,  and  involving  a  considerable  area  of  cellular  tissue,  the  term 
is  not  so  inappropriate.  By  the  term  carbuncle  is  commonly 
understood  a  broad,  flat  tumor,  with  a  doughy  feel  and  a  livid 
color.  The  cellular  tissue  is  primarily  afl"ected,  in  which  a  deposit 
of  imperfect  lymph  takes  place,  with  coloring  matter  of  the  blood 
— perhaps  blood  itself.  This  causes  a  distinct  and  somewhat  even 
elevation  of  the  superjacent  integument. 

Causes. — The  causes  may  be  given  as  local  and  general,  the 
latter  of  which  are  nearly  the  same  as  in  the  last-mentioned  kind 
of  boil.  The  vitiated  state  of  the  blood  is  the  principal  cause  of 
the  local  afiection.  The  local  cause  may  be  simply  a  weakness  in 
the  part — a  want  of  tone  in  the  vessels ;  or  it  may  be  from  a  blow 
upon  the  part,  or  some  irritation.  Whatever  the  cause,  there  will 
be  found  venous  congestion  of  the  cellular  tissue ;  then  an  imper- 
fect kind  of  fibrin  efi'used ;  and  then  the  blood  becomes  stagnant 
in  the  part,  and'the  characteristics  of  the  anthrax  are  developed. 
The  tumor  is  formed  slowly.  The  amount  of  fibrin  effused  is  not 
great,  and  it  possesses  a  low  degree  of  vitality.  When  it  degen- 
erates into  pus,  it  is  found  in  small  drops,  scattered  through  the 
mass  of  stagnant  blood  and  the  sloughing  tissue.  Although  the 
disease  commences  in  the  subcutaneous  tissue,  the  integument  is 
soon  compromised.  The  whole  action,  thereafter,  seems  to  be  a 
slow  and  imperfect  attempt  to  detach  the  substance  which  has  be- 
come a  foreign  body.  Some  portions  of  the  tissue  may  slough 
away;  here  and  there,  it  may  be  really  gangrenous.  In  the 
neighborhood  of  the  mass,  perhaps  even  at  the  line  which  marks 
its  circumference,  a  more  healthy  action  may  be  manifested ;  but 
the  blood  being  in  a  weak  or  ill-conditioned  state,  repair  is  impos- 
sible ;  and  while  repair  fails,  the  blood  is  further  poisoned  by  the 
sloughing  mass.  As  the  action  is  asthenic — slow  in  its  onset, 
slow  in  its  course — the  pain  is  never  acute,  but  sometimes, 
although  dull,  is  very  distressing.  The  constitution,  at  the  com- 
mencement at  fault,  shows,  as  the  disease  continues,  increasing 

irifiatinn     "U'l    unrripfiniofl  fbo  r»rnsf ration    ig    ft^^'findfid  with  tvnhoiu 


VARIETIES    OF    INFLAMMATION. 


129 


some  m- 


symptoms.    The  disease  occurs  more  frequently  in  middle  life  but 
equally  among  high  and  low.  ' 

Treatment-With  the  blood  in  such  a  condition,  and  the  part 
m  such  a  state,  what  can  be  done?     Evidently  it  is  of  primary 
importance  to  improve  the  state  of  the  blood,  and  to  do  so  will  be 
the  first  aim  of  the  surgeon.     Unless  the  blood  can  supply  healthy 
reparative  material,  separation  of  the  diseased  mass  cannot  take 
place,  nor  can  restoration  follow.    The  general  treatment  must,  in 
the  main,  precede  any  local  treatment.    Indeed,  judging  from  per- 
sonal observation,  I  think  that  local  treatment  should  be  avoided 
until  the  blood  is  in  a  more  healthy  state,  as  any  attempt  to  dispel 
may  result  m  the  formation  of  a  carbuncle  elsewhere;  and  I  have 
a  distinct  recollection  of  one  case  where  fatal  erysipelas  followed 
purely  local  treatment  of  a  comparatively  small  carbuncle  on  the 
temple.    The  great  desire  should  be,  to  have  established  a  healthy 
inflammatory  action  around  the  diseased  mass,  by  which  it  shall 
be  cast  off.    Until  this  is  secured,  I  have  found  poulticing,  as  well 
as  most  other  local  a])plications,  productive  of  mischief.     But 
when  the  healthy  action  is  established,  the  carbuncle  will  often 
get  well  itself.     Generally,  however,  the  work  can  be  hastened 
by  surgical  aid. 

The  general  treatment  consists  in  the  exhibition  of  tincture  of 
iron,  and  other  tonics;  generous  and  stimulating  diet,  such  as  is 
easy  of  digestion.     The  local  treatment,  afterwards,  will  be  to 
make  a  free  incision  through  the  mass,  so  that  the  fluid  within  it 
may  escape  to  some  extent.     A  small  cut  will  be  of  little  or  no 
use;  the  grumous  fluid,  with  the  drops  of  pus,  is  contained  in 
cells,  and  cannot  easily  escape:  hence  the  necessity  of  making  a 
free  division  of  the  diseased  mass.     A  crucial  incision  should  be 
made,  the  knife  being  carried  completely  from  one  side  to  the 
other  in  the  making  of  both  incisions,  and  care  should  be  taken 
to  divide  to  the  very  base  of  the  anthrax.     If  this  be  not  done 
the  fluid  cannot  find  exit.     If  however,  the  subjacent  fascia  be 
well  divided,  then  there  will  follow  a  degree  of  contraction  of  the 
several  parts,  whereby  the  wounds  are  drawn  apart,  and  by  which 
the  fluid  will  be  squeezed  out.     If  poultices  are  ever  of  use,  it 
w.]]  be  after  the  bistoury  has  been  used.     Styptics  are  sometimes 
beneficial.     I  have  known  the  application  of  pure  turpentine  to 
have  a  salutary  effect  m  facilitating  the  separation  of  the  slough. 


130 


PRINCIPLES    OP    SURGERY. 


mh 


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I' 


,'i'i 
'!;• 


.1  A 


Chilblains.— This  variety  of  inflammation  is  exceedingly  disa- 
greeable, although  not  dangerous  to  the  patient.  It  is  character- 
ized by  a  most  distressing  itching  pain.  The  feet  are  more  com- 
monly attacked.  The  cause  seems  to  be  a  frequent  or  continued 
exposure  of  the  part  to  a  wet  cold,  and  an  occasional  sudden 
change  in  the  temperature  from  the  cold  to  a  heated  state.  The 
disease  may  often  be  witnessed  in  Canada  in  winter,  coming  on  in 
the  following  manner :  The  individual  will  have  been  wearing 
leaky  boots,  or  those  with  very  thin  soles.  On  going  into  the 
snow,  the  feet  will  soon  become  thoroughly  wet,  and  then  cold. 
From  time  to  time  it  will  be  necessary  to  warm  the  feet,  which 
will  be  done  in  the  most  expeditious  manner ;  the  feet  are  thrust 
into  the  oven  of  a  heated  cooking  stove,  or  otherwise  brought  into 
close  contact  with  the  fire.  The  consequence  is,  the  boots,  socks, 
and  feet  are  rapidly  heated  before  they  can  possibly  dry,  and  the 
feet,  although  warm,  are  in  a  steaming  bath.  Relieved  of  the  cold 
feet,  the  individual  resumes  his  occupation  in  the  snow.  Again 
the  feet  become  cold ;  and  perhaps  several  times  during  a  day,  the 
feet  will  be  made  to  undergo  these  widely  diverse  changes  in  tem- 
perature. For  days  or  weeks  the  feet  may  be  thus  more  or  less 
exposed,  until  the  disease  is  established.  It  is  at  night,  when  the 
feet  are  made  bare  and  dry,  that  the  intolerable  itching  pain 
comes  on,  and  which,  in  many  cases,  becomes  almost  agonizing. 
It  can  be  readily  understood  that  the  repeated  and  sudden  changes 
of  temperature  in  the  feet  while  in  a  moist  state,  will  materially 
affect  the  tissue  and  vessels.  The  blood  is  at  one  time  stayed 
from  entering ;  at  another,  it  is  induced  to  rush  in  with  unnatural 
force,  only  to  be  again  suddenly  stopped  by  a  renewal  of  the  cold. 
Under  such  circumstances,  physiological  action  can  scarcely  be 
expected  to  go  on ;  instead  of  this,  a  pathological  condition  is  in- 
duced. The  disease  will  be  more  quickly  established  when  the 
part  is  wanting  in  natural  strength,  or  the  blood  in  vitality.  In 
some  individuals  there  is  not  so  free  a  supply  of  bloodvessels  to 
the  feet  as  in  others.  Such  persons  are  subject  to  cold  feet,  and 
will  suffer  more  quickly  from  chilblains. 

The  disease  seems  to  be  confined  solely  to  the  integument.  As 
before  said,  it  is  when  the  part  is  dry,  at  night,  and  when  the 
blood  is  circulating  through  the  skin,  perhaps  with  too  much  free- 
dom.    The  iiei  ves,  ao  frequently  exposed  to  extreme  changCB,  are 


VARIETIES    OP    INFLAMMATION. 


131 


now  in  a  pathological  state,  and  incapable  of  natural  function ; 
hence  the  characteristic  itching  pain.  The  cutaneous  nerves  are 
irritated,  but  not  to  such  a  degree  or  in  such  a  way  as  to  lead  to 
inflammation.  There  is  generally  some  redness,  but  not  so  great 
as  in  inflammation;  yet  sometimes  the  irritation  is  sufficient  to 
create  inflammatory  action,  when  the  redness  will  be  correspond- 
ingly great.  As  a  general  thing,  it  may  be  said,  the  symptoms 
indicate  physiological  rather  than  pathological  action. 

Treatment.— Obviously  the  first  thing  is  to  remove  the  cause. 
Having  an  understanding  as  to  what  leads  to  the  disease,  precau- 
tion must  be  taken  to  prevent  the  first  causes ;  and,  these  being 
removed,  nature  will  often  be  quite  able  to  restore,  and  that 
speedily.  But  the  surgeon  may  be  called  upon  to  treat  the  tor- 
turing pain.  To  do  this  the  application  of  a  coating  or  sodative 
lotion  will  be  found  serviceable.  A  lotion  of  lead  and  laudanum 
I  have  found  serviceable.  Warm  applications  are  almost  always 
otherwise  than  beneficial.  Cold,  on  the  contrary,  is  generally 
grateful.  Another  lotion  which  I  can  recommend  is  of  tincture  of 
iron  and  belladonna. 

Frostbites.— The  abstraction  of  heat  from  the  part  exposed 
may  be  so  great  as  to  entirely  destroy  the  vitality  of  the  tissue, 
and  arrest  therein  the  circulation  of  blood,  consequently  causing 
gangrene.  On  the  other  hand,  the  part  may  be  but  slightly  af- 
fected ;  and  then  every  condition  between  the  two  will  naturally 
be  met  with.  In  some  cases  there  will  be  but  a  trace  of  vitality 
in  the  aff"ected  part ;  in  others  there  will  be  only  a  slight  dis- 
turbance of  the  natural  vitality.  But  it  is  not  by  the  immediate 
effects  of  cold  that  destruction  alone  takes  place.  When  the  cold 
has  been  intense,  although  not  sufficient  to  destroy,  there  is  often 
a  reaction  so  great  as  to  overcome  the  weakened  tissues.  The 
temperature  of  the  part  is  suddenly  increased,  and  the  blood 
rushes  into  the  part.  The  vessels  are  unable  to  resist  the  pressure 
made  upon-  them,  and  are  overcome,  so  that  stagnation  of  blood 
ensues,  and  the  whole  structure  is  doomed  to  destruction.  In 
these  two  ways  the  cold  may  cause  death  of  the  tissue,  directly 
and  indirectly. 

The  parts  more  ordinarily  frozen  arc  the  feet,  hands,  ears,  or 
some  part  of  the  face ;  and,  consequently,  aside  from  the  destruc- 
tion of  tissue,  there  is  the  important  consideration  of  deformity. 


V, 


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in 


11  ;      IS 

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111 

i     I 

I    i 

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132 


PRINCIPLES    OF    SURGERY. 


It  therefore  behooves  the  surgeon  to  endeavor  to  limit  the  extent 
of  disease — the  degree  of  gangrene;  because,  when  the  tissue 
perishes,  it  is  the  same,  as  in  any  other  kind  of  gangrene,  and  will 
reqifire  the  same  treatment.  It  is  only  while  the  tissue  is  yet 
in  a  frozen  state  that  hopes  may  exist  of  averting  or  limiting  de- 
struction ;  and  it  is  of  the  treatment  while  in  that  state  I  have 
now  to  speak. 

Treatment. — The  surgeon  should  remember,  when  called  upon  to 
treat  a  frozen  limb  (but  he  will  more  frequently  be  called  after  reac- 
tion has  taken  place),  that  the  temperature  must  be  very  gradually 
raised,  the  circulation  gradually  restored  in  the  frosted  structure. 
The  restoration  of  temperature  must  be  from  within  ;  the  heat  must 
come  from  the  individual  by  the  blood  slowly  creeping  into  the  ves- 
sels of  the  part.  A  more  certain  way  of  destroying  the  tissue  can- 
not be  followed  than  to  cause  thawing  on  the  surface  before  it  has 
taken  place  in  the  deeper  part.  Although  the  frost  is  removed, 
blood  cannot  enter.  Infiltration  of  serum  ensues,  and  moist  gan- 
grene is  the  result.  Friction,  so  often  practised  by  the  ignorant, 
will  only  increase  the  danger.  Rubbing  a  part  will  be  sufiScient 
often  to  prevent  the  freezing,  and  is  an  excellent  method  of  re- 
storing the  circulation  when  it  has  begun  to  flag  under  the  de- 
pressing influence  of  cold;  but  when  a  part  is  actually  frozen  it 
should  never  be  adopted,  as  the  conditions  are  widely  diff'erent. 

In  order  to  fulfil  the  indications  above  specified,  the  patient 
must  be  placed  in  a  comparatively  cool  room,  while  snow  or  some 
refrigerating  application  is  used  to  the  frozen  part.  The  applica- 
tion of  cold  is  in  reality  to  prevent  the  external  part  from  thawing 
until  the  deeper  has  been  restored.  When  the  neighboring  tissue 
increases  in  temperature  it  will  be  known  that  the  deeper  portion 
is  being  entered  by  the  blood ;  and,  as  the  lower  stratum  is  gradu- 
ally restored,  the  external  application  will  be  increased  in  tem- 
perature. If  snow  is  available,  it  will  be  preferable  to  anything 
else ;  but,  I  repeat,  that  the  part  must  never  be  rubbed,  not  even 
with  snow.  When  the  circulation  is  fully  and  safely  restored, 
strict  rest  and  attention  to  position  must  be  observed.  In  severe 
cases  there  is  great  danger  of  subsequent  inflammation.  The  tone 
of  the  capillaries  has  been  seriously  impaired ;  while  the  blood, 
uncontrolled,  rushes  into  the  part,  and,  overcoming  the  little  re- 

mnmrnnr  nnwpr  to  contract,  soon  leads  to  transudation  of  lymph. 
or ■-    • 


<   «i\' 


VARIETIES    OF    INFLAMMATION. 


188 


The  congestion  may  bo  active  or  passive,  and  will  be  attended  with 
corresponding  results.  Sometimes,  as  before  observed,  the  sudden 
inrush  of  blood,  when  reaction  is  consummated,  will  soon  terminate 
in  the  death  of  more  or  less  of  the  affected  structure.  Frequently 
it  will  be  a  matter  of  doubt  as  to  how  much  will  recover  and  how 
much  perish.  In  such  cases  the  same  course  of  treatment  will  be 
pursued  toward  the  part  as  if  certain  of  its  recovery.  When  a 
portion  has  perished,  the  treatment  for  gangrene  will  be  adopted. 

Burns  may  be  occasioned  by  some  hard  substance,  as  a  metal, 
or  a  burning  coal,  or  by  hot  water  or  other  fluids.  The  burn  may 
actually  destroy  the  tissue,  or  only  affect  or  derange  its  vitality. 
Often  one  part  will  be  destroyed,  and  another  part  only  deranged 
or  partially  destroyed.  A  peculiarity  of  burns,  always  present, 
is  the  exalted  sensibility  of  the  nerves  which  are  affected,  if  not 
entirely  destroyed.  When  the  skin  is  detached,  so  as  to  expose 
the  nerves  to  the  air,  the  pain  is  most  acute  and  torturing.  In 
all  kinds  of  burns  this  sensitiveness  is  present,  and  constitutes  the 
most  prominent  symptom.  It  is  not  the  pain  of  inflammation ;  it 
seems  to  be  solely  due  to  exaltation  of  nervous  function.  The 
explanation  is  not  easy.  Conjectures  may  be  ventured,  but  in- 
vestigation has  not  fully  solved  the  problem.  It  may  be  that  the 
great  and  sudden  heat  so  changes  the  elements  of  the  nerve-tissue 
that  it  is  incapacitated  for  the  natural  function ;  or,  perhaps,  the 
heat  acts  chemically  upon  one  or  more  elements  of  the  tissue, 
whereby  its  electrical  condition  is  disturbed.  The  great  practical 
fact,  however,  for  the  surgeon  is,  that  the  contact  of  air  induces 
extreme  pain,  and  one  which  indicates  an  important  part  of  the 
treatment. 

Causes  and  Division. — When  the  burn  is  made  by  a  hard  sub- 
stance, more  or  less  of  the  part  will  be  charred.  When  a  fluid  is 
the  substance  which  has  acted,  the  skin  Avill  be  at  once  deprived 
of  its  vitality;  but  it  may  remain  intact,  unbroken.  Beneath 
serum  will  rapidly  be  poured  out,  and  also  liquor  sanguinis.  Here, 
then,  is  a  general  division  into  two  kinds.  Another  and  a  con- 
venient division  is  generally  given,  based  upon  the  degree  of  depth 
to  which  the  structure  is  involved.  1st.  Where  the  skin  alone  is 
burned,  but  not  destroyed.  2d.  Where  the  skin  is  quite  de- 
stroyed. 3d.  Where  the  subcutaneous  structures  are  extensively 
involved. 


i 


1| 


i 


184 


PRINCIPLES    OF    SURGERY. 


Prognosis. — Burns  are  generally  attended  with  a  great  consti- 
tutional shock,  which  in  children  is  very  often  fatal.  The  degree 
of  shock,  and  therefore  danger,  depends  more  upon  the  extent  of 
integumental  surface  involved  than  the  depth  to  which  the  burn 
extends.  Burns  are  exceedingly  fatal  to  children,  more  especially 
when  upon  the  thorax  and  abdomen.  Although  at  first  there  may 
be  little  or  no  constitutional  prostration,  yet  it  is  likely  to  present 
itself  after  a  week  or  ten  days.  Sometimes  inflammation  of  the 
bowels  arises  from  sympathy  and  causes  death.  In  every  case  of 
extensive  burns  in  children  the  prognosis  must  be  doubtful.        » 

Treatment  has  already  been  indicated.  The  great  pain  has  a 
profound  efiect  upon  the  system,  and  may  lead  to  exhausting  in- 
flammation. The  healing  process  is  slow ;  the  lymph  of  the  liquor 
sanguinis  does  not,  for  some  reason,  undergo  that  development 
natural  to  the  healing  process.  The  supply  is  too  great,  and  its 
vitality  is  too  high ;  it  does  not  quickly  coagulate,  and  therefore 
flows  away  with  the  serum.  This  continued  discharge  will  soon 
exhaust  the  strength  of  the  patient.  The  overactive  nerves  of 
the  skin  are  excited  by  exposure  to  air ;  they  should  therefore  be 
protected,  if  possible,  and  at  once. 

In  cases  of  scald  the  greatest  care  must  be  taken  to  preserve 
the  natural  covering,  although  dead.  Often,  unfortunately,  this 
will  have  been  sacrificed  in  removing  the  clothing.  If  the  surgeon 
be  present  in  time,  let  the  garment  of  cloth  or  boot  be  cut  off"  with 
care.  When  the  cuticle  is  gone,  the  covering  substituted  must  be 
something  that  will  not  increase  the  irritation  of  the  nerves.  To 
meet  this  requirement  many  things  have  been  recommended.  A 
common  and  a  domestic  agent  is  wheaten  flour.  I  have  found  its 
eflfects  the  most  happy  in  a  large  number  of  cases ;  it  requires  to 
be  applied  freely.  The  gluten  of  the  flour  uniting  with  the  fibrin 
forms  an  impervious  coating.  I  cannot  conceive  a  worse  procedure 
than  for  the  surgeon,  having  been  called  to  attend,  and  finding 
the  part  covered  with  flour,  and  perhaps  cotton-wool,  to  remove 
that  covering,  in  order  to  see  the  nature  of  the  burn — to  do  some- 
thing. Even  were  he  to  renew  the  application,  the  temporary 
exposure  may  have  turned  an  evenly  balanced  scale  against  the 
life  of  the  patient.  If,  however,  the  pain  continue,  the  surgeon 
should  examine  the  part,  not  perhaps  to  remove  what  has  been 
applied,  but  to  increase  its  efficiency.     I  repeat,  I  have  used 


VARIETIES    OJ-    INFLAMMATION. 


135 


flour  so  often,  and  with  such  complete  success,  that  I  never  think 
of  using  anything  else,  unless  it  first  fail ;  and  I  do  not  remember 
to  have  seen  any  other  application  control  the  pain  when  it  did 
not.  In  every  case,  if  the  surgeon  finds  the  burned  surface  covered 
with  anything  and  the  pain  has  ceased,  he  should  by  all  means 
leave  the  covering  alone.  Thercare  other  applications  deserving 
of  notice,  such  as  a  thorough  clothing  of  cotton-wool,  linseed  oil, 
and  lime-water  in  equal  parts.  But,  perhaps,  the  one  of  most 
importance  to  be  used  after  some  hours,  when  the  nerves  are  very 
sensitive,  is  turpentine  in  the  form  of  an  ointment.  I  have  seen 
it  afford  decided  and  grateful  relief.  Sedatives  may  be  useful, 
but  turpentine  seems  to  enjoy  a  peculiar  advantage,  to  possess  a 
specific  property  in  allaying  the  pain.  It  is  the  concurrent  testi- 
mony of  many.  Its  mode  of  action,  however,  is  unknown.  The 
opinion  may  be  hazarded  that  it  restores  the  equilibrium  in  the 
elements  of  the  nerves,  and  so  diminishes  their  undue  sensibility. 
However  this  may  be,  it  promptly  gives  comfort  and  promotes 
restoration.  When  a  portion  is  actually  destroyed,  made  gangre- 
nous, it  will  have  to  be  separated  in  the  ordinary  way.  While  this 
is  being  done  by  nature,  the  surgeon  must  endeavor  to  control  the 
tendency  to  extreme  action.  During  the  process  of  detachment, 
as  well  as  while  healing  is  taking  place,  the  nerves  retain  their 
extraordinary  sensitiveness. 

In  scalds  there  is,  generally,  a  rapid  collection  of  serum  under 
the  cuticle.  While  it  is  so  necessary  to  preserve  the  cuticle,  it  is 
equally  so  to  make  a  way  of  escape  for  this  fluid,  because  its  pre- 
sence increases  the  pain.  To  let  it  out,  small  punctures  must  be 
made  from  time  to  time.  The  danger  of  constitutional  prostra- 
tion must  be  remembered,  and,  as  far  as  possible,  averted,  by  the 
exhibition  of  good  diet  and  suitable  stimulants.  As  healing  slowly 
progresses,  and  is  finally  consummated,  there  is  exhibited  a  great 
tendency  to  contraction ;  and,  when  the  cicatrix  is  fully  formed, 
there  may  result  considerable  deformity.  The  fibrin  is  slow  to 
coagulate  and  form  granulations,  because  of  its  high  vitality ;  but 
when  it  does  take  on  that  action  it  contracts  with  great  firmness. 


I  f    ;;« 


The  next  two  varieties  of  inflammation  in  our  category  are 
hemorrhagic  and  scorbutic.  As  these  belong  exclusively  to  the 
practice  of  medicine,  they  will  not  be  considered  in  this  work. 


m\ 


136 


PRINCIPLES    OP    SURGERY. 


CHAPTER    XVI. 


Scrofulous  Inflammation — Causes ;  "Tubercle- 
Treatment. 


-Scrofula — Terminations — 


r. 


riwA'  i^uuriihe 


Of  this  variety,  very  much  might  be  said.  But  it  does  not 
come  within  the  province  of  this  work  to  consider  the  disease  of 
scrofula  in  detail — to  fully  discuss  its  pathology  and  consider  its 
treatment.  It,  as  well  as  the  two  referred  to  in  the  last  chapter, 
is  a  disease  pertaining  to  medicine ;  yet  it  very  frequently  comes 
under  the  notice  of  the  surgeon,  either  as  cause  or  effect  of  sur- 
gical complaint.  A  diseased  of  such  general  prevalence,  and  with 
tendencies  so  fatal,  involving  in  many  cases  the  life  and  happiness 
of  families,  cannot  but  command  the  attention  of  both  surgeon 
and  physician.  It  is  therefore  deemed  expedient  to  devote  a  short 
space  to  the  subject. 

Often  will  the  surgeon  be  consulted  with  respect  to  an  abscess 
located  in  the  neck,  generally  just  below  the  chin,  and  at  one 
side.  Upon  inquiry,  it  will  be  learned  that  at  the  first  there  was 
a  small  lump ;  small  and  painless  generally,  but  at  times  causing 
a  little  uneasiness.  Liniments  and  numerous  other  applications, 
very  likely  the  tincture  of  iodine,  had  been  frequently  used,  with 
only  the  effect  of  making  it  increase  in  size  and  soreness.  After 
a  time,  perhaps  several  months,  symptoms  of  inflammation  pre- 
sented themselves  in  the  part,  and  at  last  the  tumor  was  found  to 
have  been  converted  into  a  chronic  abscess.  An  opening  being 
made,  the  contents  were  seen  to  consist  of  a  thin,  curdy  pus,  with 
perhaps  solid  particles,  and  also  the  debrin  of  the  ulcerated  tissue 
intermixed.  In  the  neighborhood  of  the  abscess  will  often  be  dis- 
covered other  small  lumps,  like  the  original  one ;  some  small,  some 
larger,  perhaps  some  beginning  to  soften.  Now,  these  hard  bodies 
arc  lymphatic  glands  in  which  something  has  been  deposited,  and 
in  80  large  a  quantity  as  to  impair  the  function  of  the  gland,  and 
at  last  to  desti  oy  it.  It  is  this  deposit  which  has  caused  the  in- 
flammation of  the  gland,  and  the  abscess,  and  then  the  ulceration 
or  sloughing  of  the  gland  i  honco  the  Dcculiar  character  of  tho 


SCROFULOUS    INFLAMMATION. 


137 


contents  of  the  abscess.  The  question  arises :  What  was  this  ma- 
terial which  had  been  deposited  in  the  gland  ?  What  the  source  ? 
What  is  its  nature  ?  To  consider  these  questions  fully,  and  ad- 
duce all  that  might  be  advanced  respecting  them,  is  quite  beyond 
my  present  purpose.  Suffice  it  to  say,  that  this  deposit  is  of  a 
fibrinous  nature,  and  its  source  must  be  the  blood.  We  have  before 
learned  that  fibrin  may  be  possessed  of  too  much  vitality,  or  it  may 
be  wanting  in  natural  vitality.  It  may  be  prone  to  degenerate,  or 
be  liable  to  sudden  death,  even  while  within  the  living  body. 

It  would  seem  that  in  scrofula  the  fibrin  of  the  blood  is  devoid 
of  vitality,  and  under  certain  circumstances  will  separate  from  the 
blood  and  be  deposited  in  one  or  more  of  the  various  tissues,  but 
showing  a  preference  for  certain  ones — at  least  it  is  found  more 
frequently  deposited  in  them.  I  have  said  that  the  source  of  this 
morbid  material  is  the  blood ;  but  it  may  be  asked,  how  comes  it 
that  the  lymph-glands  become  the  abode  of  the  deposit  ?  It  is 
true,  the  glands  discharge  a  peculiar  duty  apart  from  the  circula- 
tion of  the  blood ;  but  it  must  be  remembered  that  there  is  fibrin 
in  the  lymphatic  vessels,  which  courses  along  through  the  lymph- 
atic system  to  mingle  with  the  blood.  And  it  would  seem  as  if 
the  glands,  standing  as  sentinels  to  protect  the  blood,  strive  to 
arrest  the  morbid  material  as  it  seeks  to  enter  the  mass  of  blood, 
and  by  so  doing  become  the  seat  of  deposit. 

The  glands  in  every  part  of  the  body  are  susceptible,  as  they 
are  exposed.  It  is  in  the  young  that  deposit  in  the  glands  most 
frequently  takes  place.  It  occupies  the  interstices  of  the  tissue, 
and  so  constitutes  what  is  understood  to  be  scrofula.  At  a  more 
advanced  period  of  life,  the  deposit  is  found  in  other  as  well  as 
the  glandular  system,  and  shows  itself  in  a  more  perceptible  state, 
being  in  the  form  of  tubercles,  thus  constituting  what  is  called 
tuberculosis.  Scrofula  and  tuberculosis,  then,  are  the  same  dis- 
ease :  only  that  the  former  is  incident  to  childhood,  and  is  charac- 
terized by  infiltration  of  the  matter  in  the  interstices ;  while  the 
latter  is  more  common  to  adult  age,  and  is  known  by  the  existence 
of  the  matter  in  appreciable  (luantitics,  forming  the  tubercle.  In 
every  case,  the  separation  of  the  fibrin  from  the  blood  takes  place 
in  a  manner  which  may  bo  said  to  be  unaccountable.  Possessing 
a  low  degree  of  vitality,  as  manifested  by  a  quick  coagulation  and 
liasty  aeath,  it  soon  beeoiaes,  to  all  intents  and  purposes,  a  foreign 


>  iil 


1 8,5;    ' 


138 


PRINCIPLES    OP    SURGERY. 


w-   ■ 


Lm  J»'i  ic 


body.  At  the  best,  now  and  then,  there  is  but  the  slightest  dis- 
play of  life  in  the  matter.  There  is  a  total  absence  of  blood- 
vessels in  its  substance,  as  well  of  nerves  and  absorbents.  If  you 
examine  with  the  microscope  a  portion  of  the  tubercular  matter, 
the  proof  is  conclusive  that  vitality  is  absent.  There  is  no  perfect 
cell,  such  as  belongs  to  healthy  fibrin.  The  broken-down  walls  of 
aborted  cells  may  be  seen ;  and  now  and  then,  soon  after  the  de- 
posit, a  whole  cell  may  be  discovered,  when  the  disease  is  not 
fully  developed.  But  in  this  cell  can  never  be  seen  a  single 
sound,  life-enduring  nucleus;  instead,  there  may  be  recognized 
the  cell  filled  with  granular  matter,  derived  from  the  fruitless 
attempts  to  conceive  offspring. 

But  what  is  this  disease  of  the  fibrin  ?  Why  is  it  thus  disposed 
to  separate  itself  from  the  blood  to  which  it  belongs  ?  Why  has 
it  assumed  a  low  standard  of  vitality  ?  Why  does  it  so  quickly 
die  when  it  has  parted  from  the  blood  ?  The  above  questions  have 
often  been  asked  and  answered,  or  attempts  have  been  made  to 
answer  them. 

The  fibrin  of  the  consumptive  blood,  like  a  species  about  to  be- 
come extinct,  is  incapable  of  resisting  anything  which  tests  its 
strength.  Efforts  are  made  to  display  vitality,  but  they  are  gene- 
rally abortive.  In  whatever  way  the  fibrin  of  the  b'ood  is  elabo- 
rated, the  old  race  seems  to  have  deteriorated,  and  is  being  suc- 
ceeded by  a  race  still  lower  in  the  scale  of  animal  life.  The 
offspring  is  puny  and  sickly,  although  numerous,  and  is  incapable 
of  discharging  the  duties  which  belong  to  it.  The  current  of  its 
usefulness  is  turned  aside  into  abnormal  channels,  only  to  destroy. 
The  deterioration  of  species,  the  gradual  decline  and  final  cxter- 
minutioti  of  individual  families  of  the  human  race,  is  a  subject  of 
interest  and  importance,  and  has  engaged  the  attention  of  many 
scientific  men.  With  th  is  subject  the  questions  under  consideration 
are  intimately  connected ;  the  solving  of  one  problem  will  explain 
the  other.  As  the  causes  which  lead  to  the  destruction  of  indi- 
vidual races  may  require  the  lifetime  of  generations  to  consummate 
the  effect,  so  with  consumption.  It  may  be  that  it  is  a  law  of 
animal  life  that  decline  and  death  shall  como  to  races,  as  to  indi- 
viduals, and  that  they  shall  be  wrought  by  changes  in  the  elements 
of  the  fabric,  aiuilogous  to  those  which  are  apparent  outwardly  in 

Xne  race  itSCU.       X>ut  nv  wnvrsc   Dasjucca  U  in  lO  ct-lrn.  i^.-t    -ti?7*-t*-7v  «"•* 


SCROFULOUS    INFLAMMATION. 


139 


the  causes  thereof,  who  so  often  finds  that  malady  is  the  inevitable 
result  of  a  violation  of  physiological  laws,  is  disposed  to  seek  for 
such  causes  of  deterioration  in  the  human  frame,  and  in  the  non- 
observance  of  physiological  laws.  The  belief  cannot  be  shaken 
that  the  aggregate  of  human  life  might  be  lengthened,  and  that 
life  might  be  made  less  painful  and  better  fitted  to  discharge  its 
high  duties.  We  cannot  believe,  that,  live  as  we  may,  the  extinc- 
tion of  races  must  come. 

Causes. — With  respect  to  the  causes  of  scrofula,  there  is  reason 
to  believe  that  a  want  of  cleanliness  of  the  skin  is  one,  at  least,  of 
them.  The  skin  may  be  considered  an  excretory  organ,  which 
throws  out  upon  its  surface  effete  material,  that  ought  to  be  re- 
moved therefrom.  But  in  how  many  instances  is  it  allowed  there 
to  remain,  the  skin  being  unwashed  for  months,  perhaps  for  years. 
The  matter  is  constantly  being  reabsorbed,  again  to  enter  the 
system.  We  have  seen  that  the  glands  are  often  sufferers  in 
scrofulous  disease,  and  may  we  not  look  upon  that  fact  as  sup- 
porting this  hypothesis  ?  Not  that  the  effect  upon  the  fibrin  is 
immediate ;  on  the  contrary,  it  may  be  a  long  time  before  the 
disease  is  fully  engendered,  for  if  the  other  excretory  organs  be 
in  an  efficient  condition,  the  fault  of  the  skin  may  be  in  pitrt  com- 
pensated for. 

A  second  cause  which  is  given  is  the  frequent  removals  in  the 
human  race  from  one  clime  to  another,  and  the  consequent  changes 
of  diet  and  various  other  influences  connected  therewith,  which 
affect  the  life.  In  all  ages,  these  changes  have  taken  place.  It  is 
not  alone  the  emigrant  of  modern  days  going  to  a  new  country  to 
try  his  fortunes.  In  olden  time,  the  invading  army  went  forth  to 
conquer  a  new  territory  with  a  climate  unlike  that  of  their  native 
land,  and  the  army  was  followed  by  a  peopling  kinsmen,  who  re- 
mained to  live  and  to  die  in  the  uncongenial  clime.  And  in  recent 
years,  the  over-peopled  countries  of  Europe  have  sent  hither  to 
the  United  States  and  Canada  thousands  after  thousands  to  find 
homes  and  finally  their  graves.  Not  only  the  American  continent 
is  being  possessed  by  Europeans,  but  as  well  colonies  in  every  part 
of  the  globe.  Thus  we  sec,  that  from  one  cause  and  another  the 
human  race  has  ever  been  flitting;  ever,  since  Adam  took  his  sor- 
rowing depiirturo  from  the  garden  of  Eden ;  and  as  aninuils  in 
lO'rVrr  life  may  not  Tviih  impunity  be  transferred  from  one  oounlry 


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140 


PRINCIPLES    OF    SURGERY. 


to  another,  so  it  must  likewise  be  with  the  higher  animal,  man. 
The  effect  of  the  evil  might  not  immediately  present  itself;  the 
individual  who  exposed  himself  to  the  climatic  change  might  not 
feel  the  effect  even  during  his  life.  It  might  be,  the  second  or 
third  generation  had  come  before  the  disease  were  fully  developed. 
Although  man  would  seem,  to  a  great  extent,  to  be  capable  of 
adapting  himself  to  all  climes,  to  all  conditions  of  life,  to  almost 
all  kinds  of  diet,  yet  there  is  a  limit  to  his  powers  of  resistance 
and  of  recuperation.  When  two  or  more  causes  are  acting  simul- 
taneously, the  limit  will  be  sooner  reached.  On  the  contrary, 
■when  many  of  the  laws  of  life  are  not  exposed  to  violation,  the 
infringement  of  one  may  not  bring  an  early  punishment. 

But  it  m.ust  not  be  forgotten  that  in  not  a  few  cases  emigration 
seems  to  prolong  individual  life,  and  to  render  that  life  a  more 
healthy  one.  Under  certain  circumstances  it  is  undoubtedly  the 
case ;  and  I  wish  it  to  be  distinctly  understood  that  I  have  not 
undertaken  to  show  that  emigration  is  necessarily  a  cause  of  de- 
terioration ;  and  that  the  emigrant  is  necessarily  doomed  to  decay, 
and  his  family  in  time  to  d'e  out.  I  wish  to  assert  quite  a  differ- 
ent thing.  The  causes  I  have  attempted  to  explain  of  scrofula, 
due  to  emigration,  I  trust  act  not  on  all ;  nay,  I  am  sure  they  do 
not ;  perhaps  only  on  a  minority.  I  find  in  the  London  "  Lan- 
cet," of  February,  18i)8,  the  following  startling  statements  from 
the  able  editor  :  "  In  spite  of  some  fashionable  theories  of  the  day, 
we  are  disposed  to  agree  with  that  school  of  anthropology  which 
maintains  that  the  races  of  men  can  permanently  maintain  them- 
selveo  and  thrive  in  those  countries  alone  to  which  they  originally 
belong.  To  point  to  quarters  of  the  globe  at  present  peopled  by 
races  foreign  to  the  land,  and  apparently  flourishing  commercially 
as  facts  opposed  to  our  doctrine,  would  be  met  by  the  reply,  that 
annually  into  these  countries  have  been  and  still  are  imported 
thousands  upon  thousands  of  emigrants,  representing  the  best  blood 
of  the  colonizing  stock.  That  to  form  any  satisfactory  conclusion 
this  constant  replenishment  must  be  arrested,  and  a  sufficient 
length  of  time  allowed  to  elapse  to  enable  to  see  how  the  foreign 
race  could  propagate  and  maintain  itself  in  its  adopted  climo.  We 
believe  it  would  fail,  and  gradually  vanish  and  die  out."  (I) 

It  would  be  an  unpleasant  thing  to  contemplate  that  our  children 
were  destined  to  extermination  unless  thev  returned  to  the  land 


SCROFULOUS    INFLAMMATION. 


141 


of  their  forefathers.  Against  ^ny  such  strong  assertions  I  would 
enter  my  humble  protest.  The  editor  of  the  "Lancet,"  as  well 
as  other  Englishmen,  in  casting  their  eyes  across  the  Atlantic 
upon  the  North  American  continent,  have  been  unable  to  see 
aught  buta  mighty  republic.  The  inhabitants  of  British  America 
have  always  sunk  into  insignificance,  been  quite  hidden  by  their 
frontier  neighbors.  I  make  this  remark  to  add  that  in  Canada 
are  to  be  seen  quite  remote  descendants  of  two  of  the  most  promi- 
nent people  of  Europe,  the  British  and  French,  and,  I  am  prepared 
to  assert,  with  no  marked  signs  of  physical  degeneration.  The 
French  of  Lower  Canada,  even  under  many  adverse  circumstances, 
have  fully  retained  their  ancient  bodily  vigor,  and  can  compare 
favorably  with  the  present  inhabitants  of  old  France,  while  their 
number  has  increased.  Yet  their  ancestors,  many  of  them,  emi- 
grated to  New  France  two  hundred  years  ago;  and,  since  the 
colony  became  a  part  of  Britain,  no  "replenishment"  has  been 
received  from  the  old  stock. 

Turning  to  Upper  Canada  we  find  a  fact  no  less  important  and 
quite  as  antagonistic  to  the  theory  that  native  Americans  are 
doomed  to  dio  out. 

In  consequence  of  the  American  Revolutionary  war,  some  twen- 
ty-five or  thirty  thousand  United  Empire  Loyalists  were  forced 
or  induced  to  seek  a  home  in  the  Canadian  wilderness.     Many  of 
these  were  descendants  of  those  who  had  first  peopled  New  Hol- 
land along  the  banks  of  the  Hudson.     A  large  number  of  these 
United  Empire  Loyalists  settled  along  the  St.  Lawrence  and  the 
Bay  of  Quinte.      In  the  main,  indeed,  almost  altogether,  until 
very  recently,  these  old  settlers  have  intermarried.     Now  and 
then  an  emigrant  might  settle  among  them,  but  it  was  an  excep- 
tion.     The  great-grandchildren  of  those  American  pioneers  now 
live  on  the  old  homestead,  and  are  found  scattered  over  the  whole 
province.     And  although  I  have  no  positive  data  upon  which  to 
base  my  assertion,  yet,  from  careful  observation,  I  have  no  hesi- 
tation  in  declaring  that  in  physical  development,  in  slight  mor- 
tality among  the  children,  in  length  of  life,  in  powers  of  endurance, 
not  to  say  in  bravery  and  patriotism,  they  cannot  be  excelled  by 
any  class  of  emigrants. 

I  have  deemed  it  necessary  to  make  these,  in  some  respects, 
..,jin..  xvtiiuri.=,  icat,  iHt  viuw  1  nave  veuiureU  to  express  that 


ii' 


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f 


m 


ililiSl 


142 


PRINCIPLES    OF    SURGERY. 


emigration  is  one  of  the  causes  of  the  scrofulous  disease,  might 
seem  to  corroborate  the  theory  advanced  by  the  editor  of  the 
'*  Lancet."  Emigration  is  one  of  the  causes,  perhaps  not  so  much 
because  of  emigration  as  in  consequence  of  the  emigrant  not  being 
able  to  adapt  himself  in  diet  and  in  other  respects  to  the  new 
climate. 

So  much  with  regard  to  the  primary  causes  of  scrofula ;  two  or 
more  of  which  may  operate  together.  Whatever  the  causes,  how- 
ever, when  the  disease  is  once  engendered,  it  does  not  stop  with 
the  individual,  but  is  transmitted  down  to  his  children's  children. 

As  surgeons  we  may  have  only  to  treat  the  local  manifestations 
of  the  constitutional  disease ;  yet  it  were  well  to  understand  what 
are  the  measures  most  likely  to  afford  constitutional  relief.  The 
following,  perhaps,  are  the  most  important  remedial  measures  to 
which  attention  ought  to  be  paid :  1st.  Good,  easily  digested  food. 
2d.  Daily  ablution  of  the  whole  body,  always  avoiding  the  slightest 
chill.  3d.  Keep  the  organs  of  digestion  and  excretion  in  a  healthy 
and  efficient  condition.  If  these  few,  but  essential  points,  were 
attended  to,  not  only  might  the  individual  never  be  actually  at- 
tacked with  disease,  but  perhaps  his  children  might  also  enjoy  the 
same  immunity,  although  neglecting  these  rules.  Perhaps  it  is 
not  saying  too  much  to  express  the  thought  that,  if  due  attention 
were  thus  paid  to  these  physiological  laws,  the  disease  might  in 
time  be  eradicated  from  the  human  race. 

Two  general  ways  have  been  given  in  which  the  local  disease 
may  become  established.  1st.  It  may  be  diffused  through  the 
tissue.  2dly.  It  may  be  in  the  form  of  tubercle.  There  are  seve- 
ral forms  of  tubercle.  It  may  be  like  a  millet  seed  in  size,  scat- 
tered through  an  organ  {miliary) ;  or  it  may  be  in  much  larger 
bodies.  Again,  it  may  be,  although  in  bodies,  infiltrated.  Then 
the  tubercle,  whatever  its  form  or  size,  may  be  either  gray  or  yel- 
low. The  tubercular  matter  may  have  been  yellow  from  the  first, 
or  it  may  have  been  gray  at  first,  and  subsequently  have  become 
yellow.  The  only  difference  between  them  is,  that  in  the  yellow 
there  is  a  quantity  of  fatty  matter.  It  is  the  more  common  opinion 
among  pathologists  that  the  tubercular  matter  is  at  first  gray,  and 
that  it  subsequently  becomes  impregnated  with  the  oil  globules. 
Again,  there  is  the  encysted  tubercle,  which  arises  from  the  mat- 


ter 


SCROFULOUS    INFLAMMATION. 


143 


gether,  and  thus  forming  a  cyst.  Still  another  way  in  which  the 
matter  is  found  to  collect  is  in  layers,  one  deposit  after  another 
taking  place.     This  is  the  lamellated  tubercle. 

The  form  of  the  tubercle  will  to  a  certain  extent  depend  upon 
the  nature  of  the  tissue  in  which  it  is  effused^  the  closeness  of  the 
texture,  and  the  readiness  with  which  it  yields  to  pressure. 

But  why  this  effusion  or  deposit  of  tubercular  matter  ?  Why, 
instead  of  natural  nutrition,  is  there  this  unnatural  transudation  ? 
Why  does  the  fibrin  thus  separate  from  the  blood  to  become  a 
foreign  body  ?  The  diathesis  existing,  one  of  two  causes  may  act ; 
or  they  may  act  together  to  produce  the  deposit.  First,  any  tis- 
sue, naturally  weak,  may  have  bloodvessels  so  weak,  so  destitute 
of  tone,  that  the  blood  cannot  circulate  therein  in  a  normal  man- 
ner. It  will  move  in  a  sluggish  manner ;  and  the  coats  of  the 
vessels  being  lax,  the  diseased  fibrin  will  the  more  readily  transude, 
the  more  quickly  coagulate  and  die.  In  the  second  place,  any 
irritation  or  injury  to  a  part,  or,  what  is  understood  by  catching 
of  cold,  a  sudden  morbid  impression  by  which  the  blood  is  arrested 
in  its  course,  may  lead  to  the  same  effusion.  When  deposit  has 
taken  place  in  a  part,  it,  acting  as  a  foreign  body,  is  itself  a  con- 
stant source  of  irritation,  which  will  tend  to  cause  still  further 
effusion. 

Terminations.— '^&ime  will  endeavor  to  remove  this  deposit,  as 
she  does  every  other  foreign  body.  They  may,  if  the  deposits  are 
not  large,  be  removed  by  absorption  ;  yet  such  a  result,  after  de- 
posit of  true  tubercular  matter,  is  very  rare.  Sometimes  the  de- 
posit parts  with  its  more  fluid  portion  and  dries  up ;  it  will  then 
become  calcareous,  and  finally  be  surrounded  by  a  cyst.  In  such 
a  state  it  may  not  cause  any  irritation  ;  but  in  the  larger  number 
of  cases  it  eventuates  in  softening,  not  only  of  its  own  substance, 
but  also  of  the  surrounding  tissue.  When  softening  has  taken 
place,  it  will  constitute  one  form  of  abscess,  and  will  thereafter 
follow  the  ordinary  course ;  which  will  depend  not  a  little  on  the 
tissue  involved,  as  well  as  the  extent  to  which  the  deposit  had 
been  made. 

In  those  cases  which  come  more  especially  under  the  notice  of 
the  surgeon  a  favorable  issue  is  more  likely  than  when  they  are 
medical  cases.  But  even  when  the  deposit  has  boon  made  in  the 
•-!.g,.-,  «  vuFv  i/j  n,c  cHui  13  ui  naiure  ig  noc  so  rare  u»  is  commonly 


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144 


PRINCIPLES    OF    SURaERY. 


supposed.  Three  ways  are  given  by  Bennet,  in  which  the  disease, 
when  in  the  lung,  may  be  turned  toward  a  cure.  "  1.  By  the 
gradual  transformation  of  the  exudation  into  cretaceous  and  cal- 
careous concretions.  2.  By  expectoration  and  absorption  of  the 
exudation,  the  collapse  of  the  ulcerated  walls,  and  formation  of  a 
cicatrix.  3.  By  the  ulcerated  walls  becoming  covered  with  a 
smooth  membrane,  remaining  open,  and  constituting  chronic  cavi- 
ties, which  have  occasionally  been  mistaken  for  dilated  bronchi." 
And  further,  "  that  one  or  all  of  these  modes  of  arrestment  may 
be  detected  in  the  same  lung."  But  too  often  the  extent  of  dis- 
ease precludes  the  possibility  of  either  of  such  favorable  termina- 
tions. 

The  local  treatment  of  those  cases  which  are  surgical  will  de- 
pend upon  the  stage  at  which  the  surgeon  is  called.  Hopes  may 
be  entertained  of  its  dissipation,  if  it  be  not  too  large,  or  of  long 
standing.  When  an  abscess  has  resulted,  it  will  receive  the  ordi- 
nary local  treatment.  If  a  lymphatic  gland  be  involved  hope- 
lessly, it  has  been  recommended  to  allow  the  abscess  to  remain 
unopened,  not  in  the  attempt  to  procure  absorption  of  the  con- 
tents, but  to  secure  entire  destruction  of  the  gland  by  the  inflam- 
matory process,  which  otherwise  would  remain  a  long  time  before 
it  could  be  expelled  by  ulceration  and  sloughing.  As  a  general 
thing,  however,  the  abscess  ought  to  be  opened  early.  The  tissue 
to  be  expelled  may,  if  necessary,  be  got  rid  of  by  caustic,  which 
is  by  some  strongly  recommended.  The  constitutional  treatment 
will  precede,  in  most  cases,  as  well  as  accompany,  the  local. 


CHAPTER    XVII. 

Gonorrhoeal  Inflammation. 

The  gouti/,  the  rheumatic,  and  the  diphtheritic  varieties  of  in- 
flammation will  also  be  omitted  in  this  work ;  so  that  I  now  come 
to  the  gonorrhoeal  inflammation. 

It  will  bo  remembered  that  inflammation  may  le  divided  into 
specific  and  non-specific.  Gonorrhoea  is  one  of  the  specific  forms, 
being  due  to  a  specific  cause.     The  poison  is  created  by  prostitu- 


GONORRHCEAL    INFLAMMATION. 


145 


tion.  The  excessive,  irregular,  and  unnatural  irritation  due  to 
lawless  sexual  intercourse  begets  a  diseased  condition  of  the 
mucous  glands  of  the  vagina,  and  in  consequence  there  is  secreted 
an  abnornal  fluid,  which  is  highly  irritating,  and  which  in  time 
will  cause  inflammation  of  the  mucous  metnbrane  of  the  part. 
The  pus  resulting  from  this  inflammation  is  capable,  when  brought 
in  contact  with  a  healthy  mucous  membrane,  of  causing  a  similar 
inflammation;  hence  its  specific  nature.  Commonly,  gonorrhoea 
is  confined  to  the  mucous  membrane  of  the  genital  organs,  but  in 
the  female  it  may  extend  to  the  rectum.  The  eye  sometimes  be- 
comes affected.  It  may  be  conveyed  to  that  organ  by  the  hand 
or  by  a  towel,  and,  according  to  some  authority,  by  the  air,  the 
pus-cells  becoming  dry,  and  then  while  floating  in  the  air  are  car- 
ried to  that  organ.  Inflammation,  of  the  urethra  in  the  male  and 
vagma  in  the  female,  may  arise  from  other  causes,  and  in  most 
respects  the  symptoms  be  the  same;  therefore,  by  simply  looking 
at  a  case  of  inflammation  (urethritis),  the  surgeon  cannot  be 
sure  as  to  the  nature  of  the  cause.  There  will,  however,  generally 
be  other  circumstances  connected  with  the  case,  from  which  cor- 
rect  conclusions  may  be  drawn. 

Inflammation  of  the  male  urethra  may  be  produced  by  an  in- 
jury; by  riding  on  horseback;  also  from  sexual  connection  when 
there  are  other  discharges  from  the  vagina  than  the  gonorrhoeal. 
Sexual  intercourse  during  menstruation  may  produce  urethritis. 
The  woman  with  whites,  or  ulcers  of  the  vagina  or  of  the  uterus,' 
may  cause  her  husband  to  have  it.    I  have,  at  the  time  of  writing 
this,  a   clergyman   under  my  care  who  has  inflammation  very 
closely  resembling  gonorrhoea,  which  is  attributable  to  ulcers  on 
the  OS  uteri.     Thus  it  will  be  seen,  that  although  inflammation  of 
the  urethra  may  always  be  justly  regarded  with  suspicion,  yet 
other  causes  are  quite  competent  to  produce  the  disease.    Further 
than  this,  true  gonorrhoea  may  be  contracted  in  other  ways  than 
by  sexual  intercourse.     The  virtuous  may  contract  it,  and  even 
be  Ignorant  as  to  the  cause  and  nature  of  the  disease.     A  very 
common  way  is  from  sitting  in  a  water-closet,  upon  the  seat  of 
which  the  poison  has  been  left  by  a  previous  occupant.     In  this 
way  a  female  as  well  as  a  male  may  receive  the  disease. 
The  length  of  time  requisite  for  incubation  varies  very  much, 

from  a  day  or  two  to  a  for^n'-?}'*       ti*--i-  — mi    i  ^ 

-  J  K.X  t«u  m  a,  loriRignt.     iTiuuu  «iii  uepena  upon  the 

10 


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ifH 


V  'I 

i 


146 


PRINCIPLES    OF    SURGERY. 


virulence  and  quantity  of  poison  deposited  upon  the  mucous  sur- 
face. The  resulting  inflammation  has  well-marked  symptoms,  and 
as  a  general  thing  it  is  a  healthy  attempt  to  dispose  of  a  poison 
■which  is  obnoxious  to  the  part.  The  first  indication  of  the  disease 
in  the  male  is  a  redness  of  the  glans  penis,  especially  at  the  orifice 
of  the  urethra.  The  glans,  and  perhaps  the  whole  penis,  is  a  little 
swollen,  though  not  in  a  state  of  erection.  When  the  disease  is 
fully  established,  and  the  surface  of  the  membrane  is  made  tender, 
the  passing  of  urine  causes  a  distressing  smarting  pain.  Probably 
if  it  were  not  for  this  periodical  contact  of  the  urine,  the  disease 
would  run  a  more  definite  and  speedy  course ;  that  is,  the  action 
would  continue  only  until  the  poison  had  been  carried  away  in  the 
discharge,  whereupon  healing  would  take  place.  But  the  urine 
feeds  a  flame  which  another  cause  has  kindled. 

Gonorrhoea,  although  a  venereal  disease,  is  strictly  a  local  dis- 
order ;  and  although  it  may  give  rise  to  other  serious  diseases  in 
the  parts,  it  never  involves  the  constitution  beyond  what  may  be 
due  to  inflammatory  fever,  and  exhaustion  from  continued  irrita- 
tion. Besides  the  passing  urine,  there  are  causes  of  irritation, 
which  will  assist  to  continue  the  diseased  action;  inflammation 
tends  to  cause  erection  of  the  penis,  and  this  will  lend  some  assist- 
ance to  other  causes.  Sometimes  the  erection  of  the  organ  is 
embarrassed  in  consequence  of  a  spasmodic  action  of  the  engaged 
parts,  and  sometimes  from  the  eff"usion  of  lymph  external  to  the 
urethra,  which  will  prevent  a  regular  filling  of  the  tissue  with 
blood  such  as  takes  place  at  the  time  of  erection.  In  consequence 
of  this  irregularity,  the  organ  is  often  bent  with  the  end  down- 
ward, sometimes  almost  at  a  right  angle.  This  is  a  cause  of  great 
distress  to  the  patient.  The  inflammation  commences  at  or  near 
the  orifice  of  the  urethra;  but  it  extends  along  the  membrane, 
generally,  an  inch  or  two,  and  may  even  to  the  bladder.  Probably 
it  is  at  the  point  of  termination  of  the  aflected  membrane  where 
the  bending  takes  place.  This  is  called  chordee.  It  more  fre- 
quently comes  on  during  the  night,  while  the  patient  is  sleeping, 
and  is  very  likely  provoked  by  the  warmth  of  the  bed,  or  by 
lascivious  dreams.  But  the  unnatural  irritation  incident  to  the 
disease  is  a  common  cause  of  erection  during  the  waking  as  well 
as  during  the  sleeping  moments. 

The  principal  product  of  the  inflammation  is  pus  of  a  greenish 


aONORRH(BAL    INFLAMMATION. 


147 


color  and  offensive  nature.  As  before  said,  lymph  may  be  effused 
external  to  the  urethra,  and  give  rise  to  chordee.  But  a  more 
calamitous  result  may  ensue,  in  the  form  of  a  stricture.  The 
plastic  material  thrown  out  around  the  urethra  may  coagulate 
after  a  little,  and  at  the  same  time  contract,  so  as  to  diminish  the 
size  of  the  canal.  This  stricture  may  be  very  narrow,  like  a 
girdle ;  or  it  may  be  quite  broad ;  but  several  attacks  of  inflam- 
mation will  be  necessary  to  form  one  so  extensive.  When  a 
stricture  is  formed,  it  will  be  generally  the  effects  of  protracted 
disease,  or  perhaps  of  injudicious  attempts  to  arrest  the  discharge 
at  an  early  date.  The  degree  of  constriction  varies ;  it  may  be 
but  slight,  or  it  may  almost  close  the  channel.  Although  at  first 
very  little,  if  the  irritation  continue,  the  lymph  will  also  continue 
to  be  effused  and  to  be  organized,  by  which  the  stricture  will  en- 
croach more  and  more  upon  the  urethra.  Sometimes,  indeed,  the 
passage  may  become  so  far  closed  that  the  passage  of  urine  is 
impossible,  when  the  most  disastrous  results  will  follow. 

A  not  uncommon  complication  of  the  inflammation  is  metastasis 
to  the  testicles.  I  have  repeatedly  seen  orchitis  produced  by 
strong  injections  into  the  urethra  at  the  commencement  of  the 
disease,  by  which  the  discharge  was  suddenly  stopped.  But  it 
may  arise  purely  from  sympathy. 

Treatment  of  Gonorrhoea.— The  indications  for  the  treatment  of 
gonorrhoea  will  be  quickly  comprehended  if  the  cause  of  the  dis- 
ease is  considered  aright,  and  as  well  the  cause  of  the  continuance 
of  the  inflammation.  No  attempt  should  be  made  to  abort  the 
disease.  Not  only  may  orchitis  be  the  result  of  such  attempt,  but 
the  inflammation  may  thereby  be  increased.  It  may,  perhaps,  be 
arrested  for  a  little ;  but  generally  it  will  break  out  with  increased 
violence.  It  is  possible  to  destroy  the  poison,  and  prevent  in- 
flammation, by  injection,  if  it  be  used  before  the  disease  is  fully 
established;  but  the  surgeon  is  not  likely  to  be  consulted  before 
that,  and  if  he  were,  it  would  in  most  cases  be  impossible  to  diag- 
nosticate the  coming  disease.  In  suspicious  cases,  an  injection  of 
some  mild  material  might  be  given  as  a  precaution.  The  disease 
fully  established,  it  must  rather  be  controlled  than  stopped.  In- 
deed, there  is  a  certain  amount  of  poison  which  must  be  thrown 
off  in  the  discharge ;  and  as  long  as  the  discharge  continues  to  be 
thick,  and  of  a  crreenish  vpllnw   fhovo.  \a  TPo°t  i;i^^i^  _«: —  +!--„- 


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148 


PRINCIPLES    OF    SURGERY. 


and  consequently  the  disease  may  be  imparted  to  another  person. 
This  poison  disposed  of,  it  may  be  taken  for  granted  that  the  dis- 
charge would  cease,  were  it  not  for  the  acid  urine  which  in  passing 
creates  so  much  pain. 

The  chief  thing,  then,  to  which  the  attention  of  the  surgeon 
must  be  directed  at  first,  is  the  administration  of  such  medicines 
as  will  render  the  urine  less  irritating,  and  the  enjoining  of  those 
rules  as  to  diet  and  drink  which  will  tend  to  the  same  end.  To 
neutralize  the  acid  condition  of  the  urine,  alkalies  must  be  admin- 
istered. Stimulating  diet  and  drink  should  be  most  steadily 
avoided,  and  bland  food  and  drink  exclusively  adhered  to.  Meat 
must  be  abstained  from  as  a  general  thing,  at  first,  and  farinaceous 
food  used  instead.  As  a  drink,  nothing  can  be  more  useful  than 
flaxseed  tea,  to  be  taken  as  often  as  may  be  done.  To  fulfil  the 
above  indications  as  to  medicines,  I  have  been  in  the  habit  of 
using  the  following  prescription.  It  is  one  which  I  had  the 
opportunity  of  testing  and  seeing  tested,  during  a  period  of  four- 
teen months,  while  House  Surgeon  to  the  Seaman's  Eetreat,  New 
York,  where  there  were  a  large  number  of  cases  constantly  in 
hospital.  I  have  no  hesitation  in  giving  it  a  strong  recom- 
mendation: I^.  Bal.  Cop.  Sviij;  Spts.  Etheris  Nit.  Svi;  Tine. 
Opii  Camph.  gij  ;  Liquor  Pot.  3j-  M.  ft.  mist.  A  tablespoonful 
to  be  taken  three  times  a  day. 

But  I  would  not  recommend  the  exhibition  of  this  during  the 
first  stage  of  very  active  inflammation.  Copaiba,  and  also  cubebs, 
are  more  beneficial  after  the  more  active  symptoms  have  subsided, 
and  when  the  discharge  has  lost  the  peculiar  thick  greenish  ap- 
pearance. These  medicines  are  somewhat  stimulating,  and  have  a 
particular  affinity  to  the  urinary  organs ;  and  it  is  when  the  dis- 
charge  is  beginning  to  be  chronic,  the  membrane  being  in  a  morbid 
state,  that  copaiba  particularly  is  found  to  be  promptly  beneficial. 
During  the  first  stage  the  disease  should  be  treated  antiphlogisti- 
cally.  Injections  will,  under  proper  circumstances,  prove  service- 
able. At  first  they  should  be  astringent ;  subsequently  they  may 
also  be  useful.  Sulphate  of  zinc  is  a  useful  medicine  for  injection, 
and  so  is  the  nitrate  of  silver.  The  latter  may  be  used  at  ten 
grains  to  the  ounce,  being  employed  only  once ;  or  it  may  be  more 
safely  used  at  two  or  three  grains  to  the  ounce.  The  strong  solu- 
tion has  been  recommended  to  cut  short  the  disease,  but  I  cannot 


«;    , 


SYPHILITIC    INFLAMMATION. 


149 


advise  its  use.  The  milder  solution  is  often  serviceable  when  the 
discharge  is  maintained  by  the  acid  urine.  The  raw  surface  is  by 
it  supplied  with  a  coating,  and  thereby  protection  is  afforded.  The 
disease  very  often  degenerates  into  a  chronic  discharge — glee% 
which  may  continue  for  a  long  time,  with  occasional  exacerbations. 
There  may  be  but  little  pain  attending  gleet  even  when  voiding 
urine.  The  discharge  is  thinner  and  much  lighter  in  color.  Of 
course  the  patient  is  anxious  to  be  rid  of  it  as  he  was  of  the  disease 
at  first.  At  this  time  it  is  doubtful  whether  the  discharge  pos- 
sesses the  power  to  cause  disease  in  another  when  brought  in  con- 
tact with  a  mucous  surface.  If  the  medicine  in  the  above  given 
prescription  fails,  and  the  discharge  is  in  the  form  of  gleet,  the 
tincture  of  iron  may  be  tried  with  a  fair  prospect  of  being  useful. 
Diligent  inquiry  ought  to  be  made  as  to  whether  any  special  ex- 
citing  cause  is  allowed  to  operate,  such  as  venery,  or  lascivious 
thoughts,  &c.  The  painful  chordee  may  sometimes  be  allayed  or 
arrested  by  taking  a  few  grains  of  camphor  at  night.  There  are 
other  general  principles  concerned  in  the  treatment,  of  which  no 
special  instruction  need  here  be  given. 


CHAPTER    XVIII. 

Syphilitic  Inflammation— Pathology— Question  of  Duality— Hard  Chancre- 
Its  Treatment— Soft  Chancre— Its  Treatment— Buboes— Treatment  of  Bu- 
boes-Constitutional Treatment  of  Syphilis, 

Syphilis  is  a  specific  disease,  which  is  at  once  prevalent  among 
mankind  and  a  disgrace  to  humanity.  It  is  a  venereal  disease, 
resulting  from  excessive  or  indiscriminating  sexual  intercourse. 
It  is  one  of  the  scourges  made  by  the  gods  from  a  pleasant  vice. 
It  is  not  my  intention  to  investigate  the  question  as  to  th^:  way  in 
which  this  disease  originated,  nor  the  time  at  which  it  became  a 
fully  developed  disease.  It  is  sufficient  for  our  purpose  to  know 
that  the  disease  was  the  result  of  illegitimate  sexual  commerce.  It 
is  a  matter  of  more  importance  to  understand  the  probable  or  cer- 

tam    way  bv   which    tbfi    maladv  ia    Tif^vnoinataA  ir«~      -a.-hl^-n     if    i- 


I'  ll 


-It 


PRINCIPLES    OF    SURGERY. 

met  with,  it  is  a  foregone  conclusion  that  it  has  heen  contracted 
from  another  person, — that  it  has  not  been  recently  generated 
and  developed.  Gonorrhoea  may  be  generated  at  any  time  under 
certain  circumstances ;  but  syphilis  is  supposed  to  be  a  disease  of 
ancient  birth,  which  has  been  transmitted  down  from  generation 
to  generation;  perpetuated  by  sexual  contact  in  most  cases, 
nourished  by  vice  and  unrestrained  passion.  It  may  naturally  be 
supposed  that  nature  would  be  ever  making  her  efforts  to  eliminate 
the  disease  from  the  system;  but,  notwithstanding  such  efforts, 
constant  prostitution,  with,  the  accompaniments  of  filth,  imperfect 
food,  and  strong  drink,  suffice  to  keep  the  disease  in  living  vigor, 
so  that  it  is  handed  down  none  the  less  virulent  by  the  vitiated 
and  polluted.  They  constitute  the  vehicle  of  this  fearful  and  dis- 
gusting poison  as  it  passes  along  from  age  to  age,  and  from  one 
generation  to  another. 

The  disease,  as  already  intimated,  is  generally  communicated 
at  the  time  of  sexual  intercourse  from  one  to  the  other.  But  it 
may  be  communicated  by  other  means ;  and  this  is  an  important 
fact,  one  which  may  involve  the  life-interest  and  happiness  of  a 
whole  family.  It  would  seem,  from  recorded  facts  given  to  us  by 
recent  as  well  as  by  older  writers,  that  the  syphilitic  disease  may 
be  communicate-^,  not  only  by  contact  of  the  sexual  parts,  but  also 
when  the  pus  from  a  suppurating  chancre  is  placed  in  contact  by 
other  means  with  the  mucous  membrane,  or  the  skin  from  which 
cuticle  has  been  removed,  as  for  instance  by  the  hand  or  by  the 

clothes. 

There  is  a  school  of  French  syphilographers  who  hold  that  this 
is  the  only  way  by  which  the  syphilitic  disease  can  ba  communi- 
cated,— that  the  pus  from  a  suppurating  chancre,  the  primary  sore, 
is  the  only  vehicle  of  the  poison.  M.  Ricord  says,  '*  I  have  for 
many  years  had  a  number  of  nurses  at  the  Hopital  du  Midi ;  and 
I  have  often  given  them  children  to  suckle  who  were  sent  to  me 
from  the  Maternity  with  secondary  affections.  Never,  as  far  as 
my  observation  extended,  were  these  nurses  infected. 

"On  the  other  hand,  nurses  clearly  affected  with  secondary  dis- 
ease have  been  able  to  suckle  infants,  which  were  sent  as  being 
affected  with  syphilis  (but  who  only  had  had  some  simple  eruptions 
of  eczema,  impetigo,  or  porrigo),  and  never  were  these  children, 
whilst  under  my  inspection,  infected." 


SYPHILITIC    INFLAMMATION. 


151 


On  the  other  hand,  there  are  a  large  numher  of  writers,  in- 
cluding many  of  the  leading  observers,  on  this  disease,  in  France, 
Germany,  England,  and  America,  who  maintain  that  while  the 
disease  is  by  far  the  most  frequently  communicated  through  the 
pus  derived  from  a  primary  sore,  yet  it  may  under  certain  circum- 
stances be  imparted  by  one  with  secondary  sores  or  eruptions. 
But  in  such  cases,  the  disease  resulting  is  the  same  as  the  second- 
ary to  which  it  owes  its  parentage ;  in  every  case,  like  begets  like. 
(Dr.  Waller.)  According  to  others,  secondary  sores  may  produce 
the  primary  chancre  after  long  incubation. 

Venereal  sores,  or  chancres,  are  by  some  divided  into  syphilitic 
and  non-syphilitic  ;  that  is,  into  those  which  will  infect  the  consti- 
tution, and  those  which  are  simply  local  and  which  possess  no 
power  to  poison  the  system — at  least  no  power  to  enter  therein. 
It  is  only  those  which  give  rise  to  constitutional,  symptoms  that 
they  designate  true  syphilitic  sores,  notwithstanding  the  non- 
syphilitic  are  contracted  in  the  same  way,  and  are  due  to  the  same 
cause. 

But  the  question  of  duality  in  syphilitic  poison  is  yet  unsettled; 
that  is,  whether  the  chancre  which  is  followed  by  constitutional 
disease  is  a  distinct  affection  from  the  one  which  does  not  produce 
syphilization. 

Before  proceeding  to  discuss  this  question,  it  is  well  to  remark 
that  the  genitals,  which  of  course  are  the  usual  seat  of  the  primary 
sore,  though  they  may  be  found  on  other  parts  of  the  body  (I 
have  seen  them  on  the  lips  of  sailors),  may  have  sores  upon  them 
due  to  other  causes,  as  excoriations  from  intercourse  with  one  af- 
fected by  non-specific  ulcers  of  the  vagina  or  uterus. 

But  an  individual  has  been  exposed  to  venereal  sores ;  these, 
or  the  pus  thereof,  have  come  in  contact  with  the  healthy 
body ;  a  day  or  two  thereafter,  or  perhaps  a  week,  a  sore 
begins  to  form,  often  at  first  a  vesicle.  There  is  inflammation, 
and  speedy  ulceration.  The  length  of  time  necessary  for  inocu- 
lation will  depend  upon  the  virulence  of  the  poison,  and  the 
susceptibility  of  the  part  to  become  diseased.  The  extent  of 
the  sore  will  depend  upon  the  same  causes.  The  ulcers  thus 
formed  are  divided  into  two  kinds, — the  hard  chancre  and  the 
soft  chancre.  The  former  is  followed  by  syphilization ;  the  other 
is  not. 


'yiii 


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152 


PRINCIPLES    OF    SURGERY. 


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The  hard  chancre,  as  its  name  implies,  is  characterized  by  well- 
marked  induration.  It  is  generally  a  small  ulcer,  with  hard,  ele- 
vated edges,  cartilaginous  in  appearance  and  consistence,  having 
a  grayish  color.  It  may  be  so  small  as  to  escape  notice,  and 
hence  it  is  that  now  and  then  syphilization  takes  place  without 
the  individual  having  been  aware  of  the  primary  disease.  There 
is  little  or  no  discharge  from  the  sore,  which  at  the  same  time 
manifests  little  or  no  disposition  to  heal.  In  fact,  the  poison, 
constituting  a  peculiar  irritation,  has  produced  what  is  called  ad- 
hesive inflammation  of  the  most  decided  kind ;  the  lymph  eifused, 
which  ought  to  act  a  part  in  ejecting  the  poison  and  in  repairing, 
takes  on  an  intense  action,  and  in  coagulating  acquires  the  carti- 
laginous condition. 

Now,  it  is  a  question  of  great  practical  importance  whether  the 
hard  (also  called  the  Huntcrian)  chancre  is  an  indication  of  con- 
stitutional disease.  It  has  long  been  thought,  by  some  investi- 
gators and  thinkers  upon  the  pathology  of  syphilis,  that  the 
formation  of  the  hard  chancre  is  a  salutary  operation  of  nature, 
by  which  the  poison  is,  so  to  speak,  locked  up  in  the  part,  and 
thereby  prevented  from  entering  the  system.  The  poison,  being 
applied  to  the  part,  ct-eates  inflammatory  action,  and  the  resulting 
effusion,  quick  to  coagulate,  embraces  within  the  mass  the  obnox- 
ious elements ;  and  although  its  power  for  evil  might  not  be  ren- 
dered thereby  nugatory,  yet  as  fast  as  its  influence  extends,  so 
far  and  so  quickly  will  the  adhesive  barrier  be  formed.  But  this 
beautiful  theory  cannot  be  said  to  have  a  solid  foundation.  More 
recent  observation  and  investigation  would  seem  to  support  another 
theory,  antagonistic  to  that. 

It  is  declared,  by  those  who  hold  the  later  view,  that  the  hard 
chancre,  with  its  adhesive  inflammation,  so  characteristic  of  the 
disease,  is  an  unmistakable  evidence  of  constitutional  contamina- 
tion ;  that  the  disease  has  already  entered  the  system.  Wo  have 
seen  that  there  are  three  general  circumstances  which  may  deter- 
mine adhesive  inflammation,  or  suppurative  inflammation:  these 
are,  "the  state  of  the  blood,"  "the  seat  of  the  inflammation," 
"the  degree  of  inflammation."  Now,  it  matters  not  whether  the 
cause  be  one  or  the  other,  or  even  if  two  are  acting  together; 
there  must  always  be  a  space  of  time  between  the  cause  and  the 
effect.    And  it  can  hardly  be  otherwise  than  that,  while  the  poison 


w. 


SYPHILITIC    INFLAMMATION. 


153 


is  acting  to  cause  adhesive  inflammation,  it  is  also  penetrating  to 
the  adjacent  tissue ;  so  that,  although  a  barrier  of  hard  fibrin  is 
formed,  it  is  too  late  to  close  all  the  avenues  to  the  system ;  it  is, 
in  reality,  closing  the  door  after  the  beast  has  been  stolen.  Thus 
we  see  that  adhesive  inflammation  cannot  prevent  syphilization ; 
that  before  the  hard  chancre  has  had  time  to  form,  the  poison  has 
passed  beyond  the  power  of  any  restriction  it  might  place  to  it, 
although  it  may  not  yet  have  actually  found  its  way  into  the 
system. 

But  we  will  suppose  that  suppurative  inflammation  follows  the 
application  of  the  irritation.  The  lymph,  instead  of  making  at- 
tempts to  develop  itself,  immediately  degenerates  into  pus  and 
escapes— is  thrown  off.  The  benefit  is  obvious.  Not  only  is  the 
lymph  quickly  got  rid  of,  but  likewise  the  poison,  which  would 
have  been  locked  up  had  the  inflammation  been  adhesive,  is  also 
ejected.  More  than  this:  when  suppuration  is  established  in  a 
part,  there  is  naturally  a  determination  of  blood  thereto.  The 
absorbents  are  not  so  active  ;  perhaps  are  inactive.  Consequently, 
there  is  a  current  outward  instead  of  inward ;  and  so  far,  there  is 
a  vehicle  for  expulsion  of  the  poison,  not  only  of  that  which  may 
have  been  upon  the  surface,  but  also  of  that  which  may  have  en- 
tered to  the  neighboring  tissue. 

In  the  latter  kind  of  inflammation,  which  is  attended  with 
suppuration,  the  sore  being  bathed  with  pus,  we  have  what  is 
designated  the  soft  chancre.  This  ulcer  does  not  differ  in  appear- 
ance from  one  that  has  been  caused  by  other  than  a  specific 
disease.  It  is  larger  than  the  hard  chancre  ;  and,  unlike  that  also, 
there  is  generally  more  than  one.  Around  the  primary  sore  there 
are  likely  to  form,  after  a  while,  several  more.  Tlie  sore  is  well- 
defined  at  its  borders,  looking  as  if  it  had  been  cut  out;  this  is 
the  only  peculiar  mark  in  its  appearance. 

Now,  it  is  an  important  fact  that  syphilization  rarely,  if  ever, 
follows  as  a  result  of  the  soft  chancre,  although  it  cannot  be 
qucKtioned  that  it  is  quite  as  much  due  to  a  specific  disease  as  the 
hard  is.  From  these  facts  it  has  been  inferred  that  there  are  two 
kinds,  at  least,  of  syphilis;  that  one  kind  is  characterized  by  a 
hard  chancre,  followed  by  constitutional  symptoms,  and  the  other 
kind  by  a  soft  chancre,  which  is  not  followed  by  further  disease. 
But  the  correctness  of  these  conclusions  may  certainly  be  ques- 


I  ii! 


H 


154 


PRINCIPLES    OF    SURGERY. 


'.»* 


tioned.  There  are  three  circumstances,  as  just  above  stated,  which 
may  control  the  changes  which  take  place  in  lymph  subsequent  to 
its  effusion.  We  have  seen  that  after  the  application  of  the  poison 
the  inflammation  may  be  either  adhesive  or  suppurative.  Now,  it 
would  seem  that  the  poison  so  acts  upon  the  part  that  the  inflam- 
matory lymph  exhibits  a  decided  tendency  to  coagulate,  and  pro- 
bably this  is  the  natural  effect  of  the  poison  in  every  case ;  but  in 
certain  cases,  may  it  not  be  (and  I  only  offer  it  as  a  plausible 
view)  that  another  controlling  influence,  adverse  to  the  first,  comes 
into  operation,  very  likely  arising  from  the  state  of  the  blood,  by 
which  the  lymph  is  made  to  degenerate  into  pus  ?  The  conclusion 
which  I  wish  to  draw  from  the  above  is,  that  the  syphilitic  poison 
is  always  the  same,  but  its  effects  upon  the  system  may  be  modi- 
fied by  the  state  the  system  is  in  at  the  time  the  poison  is  brought 
in  contact  with  the  body.  That  it  naturally  causes  adhesive  in- 
flammation, hut  under  certain  circumstances  this  tendency  is  coun- 
teracted. That  when  it  acts  alone,  and  causes  the  hard  chancre, 
inoculation  is  the  result;  but  when  from  any  other  cause  the  soft 
chancre  is  produced,  the  poison  is  ejected  and  no  syphilization 
ensues.  When,  therefore,  a  Hunterian  chancre  is  met  with,  it 
cannot  be  inferred  that  the  constitution  is  already  affected,  and 
the  hard  sore  is  the  effect  of  constitutional  disease ;  but  that 
there  is  imminent  danger  of  such  constitutional  affection — that 
the  poison  is  being  held  in  the  most  suitable  state  to  secure 
syphilization. 

In  connection  with  this  question,  it  requires  to  be  mentioned 
that  swelling  of  the  glands  at  the  groin,  and  the  formation  of 
buboes,  is  more  generally  an  attendant  of  the  soft  chancre  than  of 
the  hard.  This  fact,  although  at  first  it  may  seem  to  oppose  the 
view  advanced,  in  reality  supports  it.  It  is  not  at  all  irrational  to 
suppose  that,  although  the  venereal  poison  is  mainly  expelled  by 
the  suppurating  sore,  yet  the  lymphatic  glands  may  be  called  upon 
to  stay  tlie  entrance  of  a  very  limited  portion — a  duty  which  they 
faithfully  perform,  even  at  the  expense  of  their  own  integrity. 
The  poisonous  material  even  here  causes  inflammation,  foUowed 
by  suppuration,  and  so  the  pus  and  poison  escape  together ;  while 
on  the  contrary,  in  the  case  of  the  hard  chancre,  the  syphilitic 
poison  has  only  the  effect  of  causing  induration  of  the  glandf^,  and 
thereby  incapacitating  them  for  their  natural  duty,  so  that  the 


SYPHILITIC    INFLAMMATION. 


166 


system  becomes  contaminated.  To  repeat:  in  the  case  of  the 
soft  chancre,  the  most  of  the  syphilitic  poison  is  cast  out  by  the 
suppurating  sore,  and  what  little  may  be  taken  up  by  the  absorb- 
ents is  arrested  at  the  first  system  of  glands  ;  consequently,  these 
glands  take  on  a  similar  suppurative  action,  whereby  is  disposed  of 
that  limited  portion  which  had  so  far  obtained  an  entrance  to  the 
general  system. 

Treatment  of  the  Runterian  chancre  will  depend,  undoubtedly, 
on  the  view  which  may  be  held  relative  to  the  question  just  dis- 
cussed. If  adhesive  inflammation  is  regarded  as  an  indication  of 
constitutional  disease,  then  the  local  treatment  will  be  simply 
directed  to  the  healing  of  the  indolent  sore ;  but  if,  on  the  con- 
trary, it  is  to  be  considered  a  sign  of  local  deposit  of  the  poison, 
of  which  a  portion  may  or  may  not  have  been  absorbed,  and  that 
the  indurated  lymph  is  holding  the  poison  in  a  manner  which  may 
favor  its  absorption,  whereas  if  this  lymph  were  to  degenerate  into 
pus  it  would  conduce  to  the  expulsion  of  the  poison,  then  the 
efforts  of  the  surgeon  will  be  to  obtain  an  action  in  the  part  which 
will  result  in  suppuration,  and  thus  turn  the  current  outward  and 
secure  the  ejection  of  the  morbid  element. 

Taking  the  riew  that  in  the  hard  and  grayish  substance,  which 
constituted  the  chancre,  there  is  a  quantity  of  poison,  the  proper 
course  would  be  to  apply  a  caustic,  so  as  to  destroy  the  whole  of 
the  substance,  and  thereby  much  of  the  poison  itself.  Nitric  acid, 
or  nitrate  of  silver,  will  do  the  work  effectually.  It  may  be  neces- 
sary to  apply  the  caustic  a  second  time ;  and  it  should  be  repeated 
until  the  characteristic  hardness  is  no  more  observed.  The  caustic 
application  will  have  the  effect  of  producing  suppuration  as  well, 
and  so  far  conduce  to  the  required  end.  But  if  the  constitution 
has  become  affected,  if  the  poison  has  already  produced  syphili- 
zation,  the  indurated  condition  may  be  expected  to  continue,  not- 
withstanling  any  local  treatment.  In  such  cases  it  will  often  be 
found  necessary  to  exhibit  such  medicines  as  will  change  the  nature 
of  the  fibrin  upon  the  chancre.  To  do  this  the  most  effectual  drug 
is  mercury ;  yet  this  medicine  cannot  be  thus  referred  to  without 
the  accompanying  remark,  that  its  administration  is  attended  with 
danger,  and  may  be  the  cause  of  serious  complications.  This  will 
hereafter  be  particularly  referred  to.  But  in  those  cases  where 
the  constitution  is  not  involved,  mercury  is  contra-indicated,  irre- 


K  \\ 

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156 


PRINCIPLES    OF    SURGERY." 


•'1    I    >A 


irf^ 


tri  .It      ,    jrjn 


spective  of  the  evils  likely  to  follow  its  use.  It  will  in  reality 
favor  syphilization  by  softening  the  hardened  substance  of  the 
chancre,  and  thereby  setting  the  poison  free,  to  be  taken  up  by 
the  absorbents.  To  repeat,  then,  the  treatment  of  the  hard  chancre 
will  in  the  first  place  be  directed  to  the  sore  alone.  Caustic  ap- 
plications will  be  made  to  it  with  the  view  of  destroying  the  coagu- 
lated and  indurated  fibrin,  and  at  the  same  time  the  poison  which 
may  remain  in  the  part.  If  the  one  application  does  not  change 
the  character  of  the  sore  the  caustic  must  be  repeated,  until  either 
the  sore  is  altered  in  appearance  or  it  becomes  certain  that  the 
constitution  is  already  involved.  When  the  fact  is  established  that 
the  peculiar  hard  soi-e  is  due  to  constitutional  poison,  and  not 
simply  to  the  localized  poison,  which  is  seeking  .an  entrance  to  the 
system,  then  the  treatment  must  be  directed  chiefly  to  the  consti- 
tution. The  course  will  be  that  which  is  followed  when  secondary 
symptoms  have  presented  themselves.  So  far  as  the  chancre  is 
concerned,  the  patient  will  be  anxious  to  have  it  healed.  Under 
such  circumstances  mercury  may  be  cautiously  administered  to 
break  up  the  chancre. 

Treatment  of  the  Soft  Chancre. — Local  applications  alone  are 
necessary.  The  nature  of  the  application  will  depend  upon  the 
character  of  the  sore,  for  all  soft  chancres  are  not  alike.  The 
sore  may  be  confined  to  the  surface  of  the  part,  or  it  may  involve 
the  sub-tissue.  Sometimes  the  poison  seems  so  virulent  that  it 
induces  ulcerative  action  or  sloughing,  or  even  gangrene.  This 
may  not  be  altogether  due  to  the  character  of  the  poison,  but 
rather  to  the  state  of  the  part,  or  the  system  of  the  individual.  A 
part  which  is  filthy  is  more  likely  to  suffer.  A  person  whose  habits 
are  irregular,  who  is  intemperate,  whose  blood  is  vitiated  from 
excess,  may  have  "  phlegmonoid  suppurating  sores,"  or  ulcerative 
inflammation,  or  sloughing,  or  even  gangrene  in  the  part  which 
has  been  exposed  to  the  syphilitic  pus. 

When  the  sore  is  quite  on  the  surface,  and  even  when  the  sub- 
jacent cellular  tissue  is  but  little  involved,  the  treatment  will  be 
comparatively  plain.  But  when  the  cellular  tissue  is  more  deeply 
concerned,  something  decided  may  be  requisite.  The  application 
of  caustic  is  commonly  recommended.  When  applied  it  should  be 
most  thoroughly  done,  otherwise  it  would  seem  to  be  attended  with 
some  little  danger.     It  should  be  so  done  as  to  destroy  the  whole 


SYPHILITIC    INFLAMMATION. 


157 


of  the  tissue  in  which  the  poison  may  reside ;  because  sometimes 
a  soft  chancre  unexpectedly  takes  on  the  character  of  the  hard, 
indicating  the  greatest  danger  of  constitutional  infection.  And 
the  use  of  the  caustic  will  in  some  cases  be  followed  by  this 
change.  However,  we  may  venture  to  suppose  that  were  the 
poison  entirely  reached,  induration  of  the  sore  would  not  ensue ; 
that  it  is  the  presence  of  the  poison  in  the  tissue  which,  influenced 
by  the  cauterization,  leads  to  the  unfortunate  result— the  forma- 
tion of  adhesive  lymph. 

It  must  be  continually  borne  in  mind  that  the  soft  chancre  will 
not  be  followed  by  constitutional  infection  so  long  as  it  remains 
such,  but  that  it  may  become  a  hard  chancre  when  exposed  to  such 
influences  as  will  beget  adhesive  inflammation.  Suppuration  should 
be  promoted,  for  thereby  it  may  be  hoped  that  the  poison  lodged 
m  the  part  will  be  discharged.  To  destroy  the  tissue  the  nitric 
acid  should  be  employed ;  its  action  is  thorough,  and  is  not  par- 
ticularly likely  to  be  followed  by  a  change  in  the  nature  of  the 
sore. 

^  When  the  syphilitic  sore  is  attended  with  ulceration,  or  slough- 
ing, or  gangrene,  the  treatment  will  necessarily  be  prompt.  What- 
ever may  be  the  cause  of  the  destruction  of  tissue  by  the  poison, 
whether  it  be  due  to  the  vitiated  state  of  the  individual  from  whom 
the  poison  is  derived,  or  to  the  one  who  has  received  it,  the  treat- 
ment will  be  of  the  most  decided  kind.  The  poison  is  causing 
destruction  of  tissue.  The  first,  the  only  step  indeed,  is  to 
promptly  destroy  the  tissue  in  which  it  is  producing  its  destructive 
eff"ect8.  Here  again  the  nitric  acid  will  prove  the  best.  (Vide 
Ulcers.) 

Treatment  of  Buboes.— It  will  be  remembered  that  the  soft, 
non-infecting  chancre,  is  the  most  likely  to  give  rise  to  swelling 
and  suppuration  of  the  glands  at  the  groin.  It  would  seem  that 
a  certain  quantity  of  the  syphilitic  virus  is  taken  up  by  the  ab- 
sorbents, but  that  it  passes  not  beyond  the  first  glands.  Being 
detained  by  them  it  creates  inflammation,  and  finally  suppuration. 
When  the  pus,  in  the  form  of  an  abscess,  escapes  from  this  bubo, 
all  the  virus  that  has  entered  the  body  is  cast  off.  But,  in  the 
case  of  the  hard  chancre,  these  glands  do  not  nlways  cscnpe.  They 
do  not  become  inflamed ;  but  they  will  bo  found  indurated  and 
somewhat  enlarged.    The  lymph  eff-used  in  the  gland  quickly  nnn^u- 


158 


PRINCIPLES    OF    SURGERY. 


'    r 


mlf  ill 


I 


lates.  As  a  general  thing,  when  this  condition  of  glands  exists, 
the  constitution  is  already  involved ;  constitutional  syphilis  will 
ensue.  It  is  thought,  by  some  recent  writers,  that  the  avenue  by 
which  the  virus  enters  and  infects  the  system  is  not  by  the  lym- 
phatic system  of  vessels,  but  directly  through  the  blood  circulating 
near  the  chancre.  This  may  be  regarded  as  an  unsettled  question. 
When  the  glands  at  the  groin  are  found  hard  and  painless,  as  it 
indicates  constitutional  disease,  the  treatment  will  at  once  be 
directed  to  the  system.  The  use  of  mercury  will  no  doubt  hasten  . 
the  dispersion  of  the  indurated  mass.  The  tincture  of  iodine  is 
very  often  used.  I  cannot  say  I  have  seen,  as  a  general  thing, 
any  benefit  from  its  use.  But  I  have  found  the  application  of 
belladonna  to  be  followed  by  prompt  and  marked  benefit.  These 
indurated  glands  may  remain  for  months  without  giving  any  spe- 
cial trouble,  except  so  far  as  it  exercises  the  fears  of  the  patient. 

The  treatment  of  the  suppurating  gland  will  in  no  way  differ 
from  that  of  ordinary  acute  abscess.  The  pus  should  be  let  out 
as  soon  as  detected.  If  the  patient  manifests  a  tendency  to  pros- 
tration, generous  diet  will  be  much  required. 

Constitutional  Syphilis. — We  have  learned  that  the  constitution 
in  many  cases  becomes  infected  with  a  blood  poison.  The  subtle 
element,  introduced  at  the  part  where  the  chancre  forms,  finds  its 
way  into  the  volume  of  blood,  and  sooner  or  later,  according  to 
circumstances,  it  is  so  multiplied  or  becomes  so  developed  that  a 
formidable  and  destructive  disease  pervades  the  who.  .tem. 
And  the  disease  thus  established  may  remain,  notwithstanding  all 
treatment,  for  a  lengthened  period  of  time ;  sometimes  it  seems  to 
be  incurable.  The  symptoms  may  from  time  to  time  disappear, 
under  the  use  of  certain  drugs ;  but  too  often  they  reappear,  or  a 
new  phase  of  this  Protean  malady  presents  itself. 

Period  of  Incubation. — The  duration  of  time  between  the  re- 
ception of  the  virus  and  the  constitutional  display  of  symptoms  is 
not  always  the  same.  They  may  appear  in  three  or  four  weeks, 
or  as  many  months  may  elapse  before  the  so-called  secondary 
syphilis  is  established. 

SymptomR. — The  constitutional  disease  is  ordinarily  initiated  by 
a  slight  irritative  fever,  and  disturbance  generally  of  the  functions 
of  the  body.     Soon  thereafter  will  appear  a  characteristic  erup- 


SYPHILITIC    INFLAMMATION. 


159 


tion  upon  the  skin.     The  mucous  membrane  may  also  be  affected, 
■which  will  be  'ndicated  by  soreness  of  the  throat. 

Varieties  due  to  Adhesive  Inflammation. — And  here,  I  venture 
to  think,  is  an  indication  of  nature  to  which  particular  attention 
ought  to. be  paid.    The  syphilitic  poison  in  the  system  is  not  there 
allowed  to  remain,  with  no  effort  to  eliminate  it.     Instead,  we  see 
an  early  attempt  to  cast  it  off.     It  seems  to  be  through  the  skin 
and  mucous  membrane  that  this  work  is  undertaken.     And  it  is 
the  presence  of  this  syphilitic  virus,  passing  through  the  skin, 
that  produces  this  exanthematous  eruption.     This  shows  how  in- 
tensely poisonous  it  is.    Its  presence  at  once  begets  irritation,  and 
often  inflammation.     The  inflammation  maintains  the  peculiarity 
exhibited  in  the  primary  sore.     It  is  always  adhesive.     The  con- 
sequence is,  that  the  poison,  in  greater  or  less  quantity,  is  detained 
here  and  there.     We  see  it  in  minute  points  in  the  eruption,  but 
it  will  be  found  in  larger  portions  at  times,  not  alone  in  the  skin, 
but,  later  in  the  disease,  in  other  structures  of  the  body.     This 
variety  as  to  mode  and  quantity  of  virus  begets  an  equal  variety 
of  secondary,  not  to  say  tertiary,  symptoms ;  and  we  have  the 
roseola;  lichen;  syphilitic  tubercle;   syphilitic  lepra;  syphilitic 
psoriasis.     (Henry  Lee,  Syst.  Surgery.)     In  all  of  these  there  is 
the  adhesive  inflammation,  which  by  its  very  action  interferes  with 
the  eliminating  process.     As  before  said,  one  of  these  conditions 
may  disappear,  to  be  followed  by  another. 

Varieties  due  to  Suppurative  Inflammation. — But  the  inflamma- 
tion arising  from  the  virus  is  not  always  adhesive.  It  may  be  so 
for  a  time,  but  at  last  it  takes  the  suppurative  form.  Pustular 
eruptions  as  the  first  constitutional  symptom  very  rarely  occur, 
yet  sometimes  they  do  appear.  At  a  later  period,  the  fibrin  is 
more  likely  to  degenerate  into  pus.  Arising  therefrom  may  be 
seen  syphilitic  impetigo,  or  syphilitic  ecthyma.  (Cazenave,  Syst. 
Surgery.)  Sometimes  serum  only  is  effused,  and  there  is  formed 
syphilitic  herpes,  eczema,  &c.  (Lee.)  These  varieties  of  eruption, 
tubercles,  and  pustules,  may  be  found  upon  the  skin  or  mucous 
membrane,  but  perhaps  more  frequently  on  the  skin. 

Tertiary  Symptoms.— But  the  action  may  not  be  alone  suppu- 
rative, but  also  ulcerative.  The  virus  at  first  provokes  adhesive 
inflammation.  The  half-organized  fibrin  which  results  may  after 
a  time  not  only  perish,  but  likewise  involve  the  adjacent  natural 


ill.  ^M 


fm 

";     '  ■'■"V  ;'Jt 


lil 


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:  I 


If 

I 

160 


PRINCIPLES    OF    SURGERY. 


tissue.     In  this  way  great  and  extensive  destruction  may  take 
place,  constituting  the  so-called  tertiary  symptoms. 

Liability  of  certain  tissues  to  become  involved. — The  disease  re- 
maining in  the  system  for  some  time,  there  are  certain  tissues  and 
structures  which  are  more  frequently  the  seat  of  further  deposit. 
The  iris  is  very  often  affected,  forming  syphilitic  iritis.  This, 
however,  is  commonly  included  among  the  secondary  symptoms. 
The  poison  not  being  removed  from  the  outer  membranes,  the 
subcutaneous  and  submucous  structures  will  gradually  become 
involved ;  then  the  deeper  fibrous  tissues,  as  the  periosteum  and 
the  bone ;  also  the  joints,  and  the  testicles. 

The  tertiary  symptoms,  then,  are  characterized  by  a  more  ex- 
tensive destruction  of  tissue  than  before  effected.  The  skin  will 
ulcerate  or  slough  in  much  larger  quantity,  especially  about  the 
scalp.  The  mucous  membrane  of  the  mouth  and  throat  may  be 
destroyed  to  a  distressing  and  alarming  extent,  even  so  as  to  pre- 
vent deglutition  and  produce  death.  At  the  same  time,  the  perios- 
teum may  be,  in  places,  very  much  thickened  by  half-organized 
lymph,  constituting  syphilitic  nodes;  or  the  bones  may  be  in- 
volved, leading  to  necrosis,  or  caries.  Again,  the  joints  may  be 
the  seat  of  chronic  inflammation  and  degeneration ;  also  the  testi- 
cles may  be  immensely  enlarged,  or  destroyed  by  atrophy. 

Treatment. — Having  now  traced  the  disease  in  its  onward  pro- 
gress, and  endeavored  to  give  the  more  prominent  symptoms  of 
the  various  forms  of  constitutional  affection,  the  question  may  be 
asked,  whether  anything  can  be  done  to  arrest  this  fearful  malady, 
at  least  to  palliate  it? 

The  fact  has  already  been  stated  that  nature  seemingly  endea- 
vors to  get  rid  of  the  destructive  virus,  but  that  in  these  efforts 
she  is  hindered  by  the  adhesive  inflammation  which  the  poison 
begets.  In  the  first  place,  when  an  individual  has  been  the  sub- 
ject of  an  indurated  chancre,  he  ougLt  to  commence  at  once  a 
course  of  most  regular  life.  Inasmuch  as  the  skin  seems  to  be 
the  channel  by  which  the  poison  is  to  be  eliminated,  it  should  be 
daily  cleansed  by  washing  and  thorough  rubbing.  And  even  when 
the  eruption  presents  itself,  the  bathing  ought  not  to  be  dlscon- 
tinned.  As  well,  attention  should  be  paid  to  all  the  rules  of  diet 
and  hygiene. 

With  respect  to  the  administration  of  medicines  to  cure  the 


SYPHILITIC    INFLAMMATION. 


161 


disease,  it  may  be  remarked  that  no  little  difference  of  opinion 
exists;  and  when  such  is  the  case,  some  doubt  may  be  felt  as  to 
whether  any  one  medicine  has  yet  been  discovered  which  has  the 
power  to  cure  this  disease.  The  drugs  which  stand  first  are  mer- 
cury and  the  iodide  of  potassium.  SarsapariUa  has  enjoyed  a 
high  reputation  as  a  curative  agent;  but  I  speak  from  experience 
and  the  concurrent  testimony  of  not  a  few,  when  I  say  it  possesses 
no  pecuhar  virtues  as  an  antidote  to  syphilitic  poison. 

Mercury,  in  one  form  or  another,  is  regarded  by  some  as  an 
antidote  to  the  virus.  I  will  give  the  words  of  a  recent  writer 
(Henry  Lee-Syst.  of  Surgery.)  He  says:  "There  is  one  n^di- 
cme  alone-mercury-which,  through  good  report  and  evil  report 
in  spite  of  the  strongest  prejudices  of  some  against  its  use,  and 
the  no  less  adverse  influence  of  others  who  have  employed  it  to  an 
unjustifiable  extent,  has  maintained  its  general  reputation 

"From  within  a  short  time  of  the  recognition  of  syphilis  as  a 
specific  disease  to  the  present,  mercury  has  been  extensively  em- 
ployed  m  its  treatment;  and  during  the  whole  of  that  time  the 
majority  of  surgeons  have  regarded  it  as  the  most  efficacious  of  all 
known  remedies.  It  must  be  admitted  that  mercury  has  been 
often  injudiciously  given,  and  that  it  consequently  has  done  much 
harm  It  has  nevertheless  maintained  its  reputation,  and  it  may 
be  safely  affirmed  that  general  experience  has  proved  that  no 
remedy  exists  possessing  so  great  a  power  to  extinguish  the  vene- 
real poison  as  mercury.  The  iodide  of  potassium,  to  which  allu- 
sion has  been  already  made,  possesses  in  an  eminent  degree  the 
power  of  removing  some  forms  of  secondary  eruptions,  but  does 
not,  according  to  my  experience,  either  prevent  the  occurrence  or 
the  recurrence  of  the  disease  in  the  same  way  as  mercury 

''  There  are  three  different  ways  of  administering  mercury  It 
may  be  given  internally,  in  pills  or  solution ;  it  may  be  introduced 
into  the  system  through  the  skin,  in  the  form  of  ointment ;  or  it 
may  be  employed  as  vapor,  also,  applied  to  the  skin  " 

Mercury  versus  Iodide  of  P«^«««m/«.-Notwithstanding  this 
high  authority,  I^vould  respectfully  submit  that  full  justice  is  not 
clone  to  the  iodide  of  potassium,  as  a  curative  agent.  It  must  be 
conceded  that  a  drug  which  has  the  power,  "  in  an  eminent  degree 
of  removing  some  forms  of  secondary  eruptions,"  must  possess 
some  specific  virtue.     It  is  not  argued  by  the  above-mentioned 

II 


B' 


ill 

li  ] 


J.i 


y'f -.'ifclfja 


ijl    i  I  ;  I 

,1         i  ^  ! 


t  -w 


n 


mmmmmmfmmmmium 


162 


PRINCIPLES    OF    SURGERY. 


Pi 


eminent  writer  that  it  merely  suppresses  a  disease,  which  after- 
wards exhibits  increased  virulence,  but  that  it  does  not  "prevent 
occurrence  or  recurrence  of  the  disease  in  the  same  way  as  mer- 
cury." Now,  the  various  secondary  symptoms  which  are  pre- 
sented must  be  regarded  as  efforts  of  nature  to  eliminate  the 
virus ;  and  if  a  drug  has  the  virtue  to  remove  these  symptoms,  it 
must  to  a  certain  extent  prove  an  antidote  to  the  poison— at  least 
it  assists  in  its  elimination.  And  if  the  medicine  be  continued 
diligently  for  a  sufficient  length  of  time,  I  must  say,  I  think 
almost  or  quite  as  much  benefit  will  be  experienced  by  the  patient 
as  would  be  obtained  by  the  use  of  mercury.  But  that  is  not  all. 
Iodide  of  potassium  is  not  likely  to  produce  evil  effects  upon  the 
system ;  whereas  the  exhibition  of  mercury,  even  when  judiciously 
used,  may  be  productive  of  disastrous  results. 

Mercury  is  recommended  as  the  most  efficacious  medicine  in  all 
stages  of  the  disease ;  to  prevent,  as  well  as  to  cure.  If  we  are 
expected  to  look  upon  mercury  as  a  direct  antidote  to  the  poison 
—as  a  medicine  which  possesses  the  power  to  annihilate  the  virus 

I  submit  that  the  evidence  is  wanting  to  substantiate  such  a 

view.  That  mercury  has  the  power  to  break  up  the  spots  of  ad- 
hesive inflammation,  is  well  understood.  Herein  would  seem  to 
consist  the  only  virtue  of  the  drug;  because,  when  that  is  effected, 
a  chance  is  afforded  for  elimination.  But,  as  we  have  seen,  the 
iodide  of  potassium  enjoijs  the  same  reputation,  though  to  a  less 

extent. 

Taking  all  in  all,  must  it  not  be  regarded  as  a  safer  mode  of 
treatment  to  faithfully  try,  in  the  first  place,  the  iodide  of  potas- 
sium, and  then,  should  it  fail  to  accomplish  what  is  required,  after 
due  trial,  resort  cautiously  to  the  more  potent  and  at  the  same 
time  dangerous  drug— mercury  ? 

The  aforementioned  writer  recommends,  as  far  the  best  mode 
of  using  mercury,  calomel  fumigation.  "  None  is  attended  by  so 
little  mischief  to  the  patient's  constitution,"  a  most  important 
consideration,  "and  none  is  followed  so  seldom  by  a  relapse." 
"Mercurial  inunction,"  he  says,  "is  a  very  efficient  way  of  using 
mercury ;  but  it  is  dirty,  laborious,  and  often  little  suited  to  the 
taste  of  those  who  require  its  aid."  The  following  is  the  plan  of 
fumigation  practised  and  recommended  by  this  writer.  It  can  be 
well  recommended  to  those  v/ho  wish  to  employ  the  drug :     "  It 


■  f  'i 


SYPHILITIC    INFLAMMATION. 


163 


the  apparatus)  consists  of  a  kind  of  tin  case,  containing  a  spirit- 
lamp  In  the  centre,  immediately  over  the  wick  of  the  lamp,  is  a 
small  circular  tin  plate,  upon  which  the  mercurial  powder  is  placed. 
Around  this  is  a  circular  depression,  which  is  half-filled  with  boil- 
ing water.  The  patient  places  this  on  the  ground,  and  sits  over 
It,  or  near  it,  on  a  small  cane  stool.  He  is  then  enveloped,  lamp 
and  all,  in  a  circular  cloak,  made  expressly  for  this  purpose  by 
Messrs.  Savigny.  When  a  cloak  cannot  be  procured,  a  double 
blanket  answers  the  purpose  very  well.  At  the  expiration  of  a 
quarter  of  an  hour  or  twenty  minutes,  the  calomel  which  is  placed 
upon  the  lamp,  the  water,  and  the  spirit,  will  have  disappeared 
and  the  patient  may  then  get  out  of  bed. 

"  During  the  time  the  patient  is  taking  the  bath,  he  may  inhale 
the  vapor  for  half  a  minute  or  a  minute,  on  two  or  three  different 
occasions,  with  advantage;  and  after  the  bath  is  over,  he  must 
contrive  not  to  wipe  off  the  calomel  deposited  upon  his  skin.  Pa- 
tients are  usually  recommended  to  sit  over  the  bath  for  two  or 
three  minutes  after  the  lamp  has  gone  out.  They  are  then  suffi- 
ciently cool  to  put  their  day  or  night  shirt  on,  as  the  case  may  be 
without  disturbing  the  calomel  on  the  surface  of  the  skin  A 
portion  of  that  which  is  left  there  becomes,  by  a  slow  process  of 
imbibition,  absorbed  into  the  patient's  system. 

"Amongst  the  poor,  a  less  expensive  apparatus  is  convenient. 
Halt  a  brick  is  directed  to  be  heated  to  a  dull  red  heat,  and  then 
placed  m  a  pan  having  a  little  water  in  the  bottom.     On  the  top 
of  the  heated  brick  the  mercury  is  placed.     The  patient  then  sits 
over  the  pan  for  twenty  minutes,  with  a  large  blanket,  reaching 
down  to  the  ground,  round  his  neck.    It  will  be  noticed  that  in  all 
these  arrangements,  provision  is  made  not  only  for  the  volatilization 
of  the  mercury,  but  also  for  presence  of  water  in  a  state  of  vapor 
This  is  important;  for  practically,  it  is  found  that  the  mercurial 
action  is  more  certainly  produced  and  more  steadily  maintained 
when  mixed  with  a  certain  quantity  of  vapor  of  water,  than  in 
dry  air." 

These  modes  recommended  by  Mr.  Lee  are  the  least  objection- 
able  ways  of  using  the  drug,  and  it  may  be  that  the  desired  effect 
can  be  secured  without  exposing  the  constitution  to  those  terrible 
etiects  sometimes  seen.    This  treatment  is  followed  at  all  stages  of 


*         !! 


li 


'-■j 


f  '!1- 


*i  'A 


164 


PRINCIPLES    OF    SURGERY. 


the  disease,  whether  it  be  the  primary  indurated  chancre,  or  ulcer- 
ative destruction  of  the  tertiary  symptoms. 

For   treatment  of  syphilitic   ulcers   (tertiary  symptoms),  see 
Ulcers. 


CHAPTER    XIX. 


Erysipelatous  Inflammation  —  Causes.  Varieties:  1,  Simple;  Symptoms — 
Treatment:  Local  —  Constitutional.  2.  Phlegmonous;  Pathology  — Treat- 
ment. 

This  is  the  last  form  to  he  noticed.  One  of  its  chief  charac- 
teristics is  a  tendency  to  spread,  both  by  continuity  and  contiguity. 
It  may  extend  along  the  skin  or  the  mucous  membrane,  or  to  the 
subjacent  cellular  tissue.  The  inflammation  is  the  result  of  a 
blood  poison,  which  has  been  gradually  developed  in  the  system. 
It  is  probably  due  to  the  introduction  of  some  decaying  matter, 
either  animal  or  vegetable.  It  is  a  disease  in  many  respects  like 
pyemia,  and  no  doubt  may  be  generated  in  the  same  way  as  that 
disease;  or  it  may  be  the  result  of  son-.e  extraneous  substance 
which  has  found  entrance  to  the  bloody  often  by  inhalation.  A 
period  of  incubation  passes,  during  which  there  is  no  doubt  a  pro- 
cess of  zymosis,  and  by  which  the  poison  attains  to  its  power  to 
create  a  local  inflammation.  It  is  not  improbable  that  the  local 
manifestation  is  an  extraordinary  eff"ort  of  nature  to  eliminate  the 
poison,  at  least  when  the' disease  ib  upon  the  surface  of  the  body. 
Otherwise,  it  may  be  regarded  as  truly  a  disease  of  the  tissue, 
because  that  tissue,  being  weak,  or  irritated,  or  injured,  could  no 
longer  resist  the  fatal  influence  of  the  poison  which  had  been  de- 
venped  in  the  blood. 

Synptoms. — This  affection  is  characterized  by  the  various  phe- 
nomena of  inflammation,  although  they  are  very  much  modilicd. 
Stagnation  of  blood  takes  place  very  quickly ;  the  coats  soon  arc 
dilated  and  paralyzed,  and  seem  to  be  (iuitc  incapable  of  resi.sting 
the  pressure  made  by  the  blood  circulating  therein.  The  result  is 
rapid  transudation  of  serum  and  liquor  sanguinis  with  the  coloring 


ERTSIPELATOUS    INFLAMMATION.  165 

natter  of  broken-down  red  corpnsclea,  which  are  dying  very  ra- 

S  VI  """'"'''  °'  *''  '■*■»''«'"'  i"  the  transudation 
wh,  h  g.vos  ,0  the  part  that  intense  redness  which  is  also  charac 
teristic  of  the  disease. 

ft,^...._The  causes,  already  referred  to,  may  be  divided  into 
predzspostng  and  e:ccitmg.     Anything  which  vitiates  the  system 
or  impairs  its  vitality,  thereby  making  it  more  susceptible  when 
exposed  to  the  morbid  influences,  is  a  predisposing  cause.    Of  the 
excting,  there  may  be  mentioned  infection,  atmosphere,  epidemic 
With  respect  to  the  first,  it  must  be  remembered,  a^s  a  flct^^f  co" 
SKlerable  practical  interest,  that  the  disease  may  be  conveyed  from 
one  individual  to  another,  and  in  various  ways.'  It  can  be  carried 
rom  one  house  to  another ;  and  in  the  hospital,  from  one  ward  to 
another.     The  vehic  e  may  be  the  surgeon,  the  aurse,  a  bandage. 

affl  cted  with  the  disease.  This  shows  with  what  care  the  attend- 
ants  upon  such  should  proceed;  how  necessary  it  is  to  destroy 
everything  that  has  been  used  about  the  afflicted,  and  to  thoroughly 
cleanse  the  hands  before  approaching  another  patient.  The  pofson 
emanating  from  an  erysipelatous  sore  is  sometimes  also  conveyed 
by  the  air  to  a  healthy  so.o,  and  changes  it  into  an  erysipelatous 
ont.  A  times,  there  is  an  epidemic  of  erysipelas;  it  will  prevail 
in  a  locality  for  a  time,  and  then  disappear. 

7>/..W.«*.-Various  divisions  of  erysipelas  arc  given  by  writers. 
I  may  be  made  into  idiopathic  and  traumatic;  also  symptomatic. 
J  he  first  form  belongs  more  especially  to  the  science  of  medicine, 
an.  the  second  to  surgery.  The  most  nsoful  division  is  into  simple 
'^^d  phlegmonous;  and  these  may  be  said  f  embrace  every  form 
of  the  complaint,  however  caused,  and  whet  t  it  be  idiopathic  or 
raumat.c^  The  simple  is  confined  to  the  skin  or  mucous  mem- 
brane.    The  phlegmonous  involves  tho  cellular  or  deeper  struc 

But  there  are  other  kinds  mentioned  :  kinds  which  have  received 
heir  distinctive  names  on  account  of  some  prominent  or  prevatiin« 
feature.  These  it  will  be  sufficient  to  mention.  They  are  •  aj 
mtous,hccamoor  oedema;  cellular,  where  the  c.  iilar  tissue  is 
pnncpally  aflocted ;  biliotis,  in  which  there  is  derar.gement  of  tho 
bil.ary  apparatus;  erratic,  characterized  by  a  disposition  to  move 
Irom  one  part  of  tho  skin  tn  nr..,f},„..  _..„1j...   _'       ..   ,  - 


1 

II 

1      '^ 

11 

'■I 

1 

, ' ! 

i 

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f  m 


1        i  ^ 


il 
HI 


166 


PRINCIPLES    OF    SURGERY. 


coming  periodically,  without  any  adequate  cause ;  hospital,  due  no 
doubt  to  want  of  cleanliness,  bad  ventilation,  or  other  neglect  of 
hygienic  rules. 

Symptoms  of  erysipelas  may  be  divided  into  local  and  general. 
The  constitutional  symptoms  of  the  simple  and  phlegmonous  are 
the  same,  with  this  difference :  that  in  the  phlegmonous  they  are 
more  decided  in  their  nature — are  better  marked. 

The  local  symptoms  are  the  same  as  in  healthy  inflammation, 
viz. :  pain,  heat,  redness,  swelling.     The  first  is  sharp  and  sting- 
ing— a  sensation  something  like  burning.      There  is  generally 
exacerbation  at  night.     "  The  inflamed  part  is  hot  and  painful ; 
at  first,  a  stinging  or  itching  is  felt,  which  soon  becomes  a  sharp, 
smarting,  and  burning  sensation,  with  acute  pain  on  pressure. 
The  pain  is  not  so  intense  and  unremitting  as  in  phlegmon,  nor  is 
it  attended  with  throbbing."     (Lawrence.)     Redness  is  always  a 
prominent  feature,  and  sometimes  is  very  bright,  in  consequence 
of  which  it  has  been  designated  the  rose.     It  is  not  due  simply  to 
an  increased  quantity  of  blood  in  the  part,  but  to  a  common  infil- 
tration of  liquor  sanguinis  and  the  coloring  matter  of  the  blood. 
A  peculiarity  of  the  redness  is  that  it  has  well-marked  borders ; 
the  line  of  demarcation  between  it  and  the  healthy  skin  is  distinct. 
If  pressure  be  made  upon  the  part,  the  redness  momentarily  dis- 
appears.    Swelling,  as  a  general  thing," in  the  simple  form,  is  not 
present ;  but  sometimes  there  are  small  vesicles  over  the  reddened 
surface.     This  generally  indicates  a  serious  attack,  and  a  danger 
of  extension  by  contiguity  to  the  subcutaneous  structures. 

Constitutional  Symptoms.— In  the  first  place,  there  is  a  fooling 
of  lassitude,  with  headache ;  then,  considerable  depression,  per- 
haps great  prostration.  Tho  whole  of  the  alimentary  canal  is 
disordered.  Commencing  with  the  mouth,  it  is  found  dry;  the 
tongue  is  furred,  or  coated,  and  exhibits  a  tendency  to  bocomo 
brown ;  the  stomach  is  at  first  somewhat  nauseated,  and  food  is 
distasteful,  and  digestion  seems  impossible ;  tiie  bowels  are  gene- 
rally constipated  ;  the  liver  is  sluggish,  perhaps  congested,  wliich 
will  be  indicated  by  pain  in  that  region.  When  the  liver  is  thus 
involved,  the  disease  becomes  the  bilious  erysipelas.  Fever,  with 
dryness  of  the  skin,  is  at  times  very  considerable ;  not,  however, 
80  great  as  in  the  healthy  form  of  inflammation. 

The  course  and  termination  of  simple  erysipelas  will  depend 


ERYSIPELATOUS    INFLAMMATION. 


167 


somewhat  on  circumstances,  but  generally  it  runs  its  course  to  a 
favorable  issue.    In  those  cases  where  a  tendency  is  manifested  to 
extend  to  the  deeper  tissues,  the  result  is  less  likely  to  be  favor- 
able.    The  disease,  although  inflammatory,  yet  being  due  to  a 
blood  poison,  which  for  elimination  requires  time  and  suitable  con- 
ditions of  the  organs  of  secretion,  cannot,  like  ordinary  inflamma- 
tion,  be  cut  short.     It  must  run  a  certain  course ;  and  while  such 
IS  being  done,  the  products  before  mentioned  exhibit  a  quick  ten- 
dency to  aifect  the  tissue  in  which  they  are  infiltrated.    The  effused 
material  is  strongly  impregnated  with  the  erysipelatous  poison, 
and  softening  and  ulceration  speedily  follow  this  abnormal  inflam- 
mation.    In  the  truly  simple  form,  the  products  are  very  limited 
and  consequently  the  eff-ect  upon  the  membrane  is  very  slight. 
But  very  often  the  simple  form  becomes  phlegmonous ;  in  such 
cases,  the  products  are  more  remarkable  and  injurious ;  and  the  , 
result  to  the  constitucion  will  be  correspondingly  great,  causing 
very  great  prostration,  and,  if  the  system  be  weak,  terminating  in 

Treatment  of  Simple  Hrf/atpelas.— The  disease  may  not  be 
aborted,  or  brought  to  a  termination  by  treatment,  like  as  in  acute 
inflammation,  although  it  may  be  somewhat  abbreviated.  The 
principal -point  in  the  treatment  is  to  control  the  inflammation ;  to 
hmit  it  to  the  part  already  involved ;  and  should  products  result, 
give  due  attention  to  them.  The  strength  of  the  patient  must  be 
maintained,  by  suitable  means,  until  the  poison  shall  have  been 
eliminated. 

If  the  local  inflammation  can  at  all  be  regarded  as  an  eff'ort  at 
ehmination,  and  that  the  poison  is  concentrating  in  the  part  for 
that  purpose,  it  can  be  readily  understood  that  no  eff'ort  ought  to 
be  made  to  disperse  the  inflammation,  inasmuch  as  the  disease  may 
disappear  in  one  place  only  to  appear  in  another,  and  where  it 
will  be  less  tractable— less  easily  controlled.  1  have  seen  some 
cases  of  idiopathic  erysipelas  of  the  face,  in  which  powerful  means 
were  adopted  to  cut  short  the  inflammation,  and  which,  having 
accomplished  the  object  aimed  at,  was  followed  by  metastasis  to 
the  brain,  terminating  in  deatli.  Whether  the  above-ranntioned 
theory  be  correct  or  not,  there  can  bo  no  doubt  that  to  control 
the  local  manifestion  is  the  utmost  that  should  bo  sought  for. 

The  disease  is  prone  to  snread  bv  rnntlnnifv  •    t"  «>*pn  ih\~ 


n 


Mi 

III 


168 


PRINCIPLES    OF    SUKGEEY. 


abundant  experience  has  shown  that  a  solution  of  Nit.  Argent, 
will  prove  highly  efficacious.  The  application  should  be  made  not 
to  the  surface  of  the  inflamed  part,  but  to  the  tissue  around  it, 
allowing  a  distance  of  something  like  an  inch  to  intervene  between 
the  affected  portion  and  the  part  to  which  it  is  applied.  The 
caustic  so  alters  and  disorganizes  the  integument,  that  those 
changes  necessary  to  the  inflammatory  process  cannot  take  place, 
and  thus  a  barrier  is  formed,  beyond  which  the  disease  will  not  be 
able  to  spread.  The  circle  of  coated  skin  must  be  complete ;  for 
if  the  slightest  space  be  untouched  by  the  solution,  along  it  the 
redness  will  extend,  and,  when  outside,  thence  spread  on  every 
hand.  The  solution  of  silver  ought  not  to  be  applied  to  the  part 
which  is  red,  as  it  is  very  likely  to  cause  the  disease  to  extend  to 
the  deeper  structures. 

To  prevent  the  disease  from  extending  to  the  subjacent  tissue  by 
contiguity,  and  to  abate  the  existing  inflammation,  various  appli- 
cations ha  >  e  been  recommended.  It  must  not,  in  using  any  appli- 
cation, be  forgotten  that  the  inflammation  is  not  to  be  directly 
arrested,  but  rather  the  cause  should  be  removed,  and  that  there- 
after the  disease  will  naturally  incline  to  stop.  To  limit  the  dis- 
ease, sedatives  and  astringents  may  be  advantageously  employed. 
Cooling  lotions  are  often  beneficial ;  and,  on  the  contrary,  warm 
applications  may  give  great  relief,  more  especially  when  there  is 
much  tension  of  tissue  by  eff'usion  of  liquor  sanguinis.  Tincture 
of  iron,  or  sulphate  of  iron,  may  be  applied  with  very  decided 
benefit.  The  iron  acts  as  an  astringent,  and,  as  well,  seems  to 
have  a  specific  effect  upon  the  poisoned  fluid  in  the  part.  It  ap- 
pears to  supply  vitality  to  the  blood :  at  least  a  greater  degree  of 
vitality  is  exhiL.ted  by  it.  Possibly  the  iron  acts  directly  upon 
the  poison  which  is  concentrated  in  the  part,  and  destroys  it,  cur- 
ing the  inflammation,  and  at  the  same  time  the  cause  of  it. 

Oleaginous  applications  are  now  and  then  comforting  to  the 
irritated  nerves.  The  presence  of  air  seems  to  cause  some  of  the 
irritation,  and  if  it  be  excluded  the  pain  will  be  lessened ;  hence 
it  is  that  oil  aff'ords  relief.  Flour  may  prove  likewise  beneficial. 
Collodion  has  also  been  used.  The  tincture  of  iodine  has  been 
highly  recommended ;  but  it  ought  by  no  means  to  be  used  indis- 
criminately. When  the  irritation  is  great — the  action  running 
high — the  iodine  will  only  augment  the  already  too  great  action. 


ERYSIPELATOUS    INFLAMMATION. 


169 


As  an  application,  it  is  more  particularly  useful  in  the  oedematous 
form,  when  there  is  a  want  of  acute  action,  there  being  passive 
congestion  instead  of  active. 

In  the  more  serious  form  of  this  simple  erysipelas,  when  vesicles 
are  seen  upon  the  surface,  and  extensive  effusion  seems  to  be 
taking  place,  the  more  prompt  and  suitable  treatment  is  to  make 
small  punctures,  so  that  the  blood,  almost  or  quite  stagnating, 
may  escape. 

Constitutional  Treatment. — Sanitary  rules  must  be  duly  ob- 
served. The  primae  viae,  being  generally  deranged,  will  have  to 
receive  attention.  If  there  is  indigestible  food  in  the  stomach,  an 
emetic  to  remove  it  will  be  well.  The  liver,  always  torpid,  should 
be  aroused  to  action  by  a  full  dose  of  calomel  and  jalap.  To 
treat  the  disease  itself — to  destroy  the  poison  in  the  system— I 
know  of  nothing  more  useful  than  the  tincture  of  iron,  in  doses  of 
from  fifteen  to  twenty-five  drops  every  three  or  four  hours.  The 
powers  of  life  must  be  sustained  by  stimulants  and  by  beef  tea. 
With  respect  to  alcoholic  stimulants,  there  is  a  difference  of  opin- 
ion. The  late  Dr.  Todd  was  a  strenuous  advocate  for  its  use.  He 
contended  that  brandy  not  only  acted  as  a  stimulant,  but  also  as 
an  antidote  to  the  erysipelatous  poison.  According  to  the  cases 
adduced  by  him  in  his  work  on  "Acute  Diseases,"  his  success  in 
the  treatment  of  erysipelas  was  very  great.  But  other  authority, 
equally-  high,  declares  that  the  disease  can  be  governed  without 
much,  if  any,  alcoholic  stimulants.  From  not  a  little  observation, 
I  feel  no  hesitation  in  off'ering  the  opinion  that,  in  the  worst  forms 
of  the  disease,  nothing  can  take  the  place  of  alcohol,  administered 
in  one  form  or  other.  If  plenty  of  beef  tea  can  be  taken,  the 
stimulant  may  be  unnecessary ;  but  otherwise,  brandy  will  be  re- 
quired to  sustain  the  powers  of  life. 

Phh'(/monou8  Injlammation. — It  has  already  been  observed  that 
by  this  is  meant  those  cases  where  the  sub-integumental  tissues 
arc  involved.  The  disease  may  at  first  have  been  simple,  and  then 
have  merged  into  the  phlegmonous.  The  tissue  affected  may  be 
the  cellular  tissue,  or  perhaps  the  meninges  of  the  brain.  It  is 
by  far  a  more  serious  and  fatal  form  of  the  malady.  Our  atten- 
tion will  be  more  particularly  directed  to  the  cases  where  the 
cellular  tissue  is  the  seat  of  the  inffamination.  At  the  very  first 
sight,  it  will  be  seen  to  be  a  more  grave  and  serious  affection  than 


1'    SI 


m^', 


170 


PRINCIPLES    OF    SURGERY. 


i!t 


the  simple  form.  The  characteristic  redness  is  not  so  bright,  but 
it  is  deeper  in  hue.  In  the  simple  there  is  little  or  no  swelling ; 
in  this  there  is  a  good  deal,  which  is  more  diffused.  To  the  red- 
ness there  may  be  a  distinct  line  of  demarcation,  but  the  swelling 
is  not  circumscribed.  Into  the  cellular  tissue  is  at  first  determined 
a  large  quantity  of  the  vitiated  blood.  Rapid  distension  and 
paralysis  of  the  vessels  follow,  attended  by  free  effusion  of  liquor 
sanguinis  of  a  low  grade.  Very  soon  there  is  a  complete  stagna- 
tion of  blood  in  the  part,  while  the  cellular  spaces  are  distended 
with  fluid,  colored  with  the  haematine.  Following,  will  soon  be 
found  a  degeneration  of  the  ill-conditioned  fibrin  into  pus  corre- 
spondingly low.  There  will  be  no  collection  of  pus  here  or  there, 
the  matter  b^ing  distributed  through  the  cellular  tissue.  While 
these  morbid  steps  are  being  taken,  one  after  another,  the  swelling 
is  gradually  increasing ;  and,  in  accordance  with  the  general  rule, 
the  pain  is  consid^ 'able,  sometimes  very  great.  There  is  a  ten- 
dency to  speedy  ulceration  and  destruction  of  the  engaged  struc- 
tures ;  sometimes  there  is  even  sloughing. 

These  more  formidable  symptoms  in  the  part  are  attended  by 
equally  prominent  constitutional  symptoms,  Avhich  approach  to  the 
typhoid  kind.  All  of  the  constitutional  derangements  specified  in 
the  simple  are  here  present  in  an  intensified  form.  The  disease  is 
generally  ushered  in  with  a  well-marked  rigor,  which  may  be  re- 
peated. The  tendency  to  prostration  is  constant  and  often  alarm- 
ing, especially  when  there  is  delirium. 

The  result  and  final  termination  may  be  the  most  serious.  The 
inflammation  is  very  likely  to  spread  and  involve  the  deeper  struc- 
tures, and  to  extend  along  the  subcutaneous  cellular  tissue.  The 
constitution  is  in  danger  of  succumbing  to  the  combined  effects 
of  the  blood  poison  and  the  local  disease.  The  resources  of 
the  surgical  art  will  be  required  to  give  prompt  and  decided 
assistance. 

Treatment  of  Phlegmonous  Inflammation. — The  surgeon's  at- 
tention will  be  at  once  directed  both  to  the  local  affection  and  the 
constitutional  malady.  The  danger  of  ulceration,  ani  soughing 
of  the  tissue,  must  be  constantly  regarded.  The  pain  iS  distress- 
ing. It  is  due  to  triiti-adation  of  morbid  lymph,  vlMch,  may  be, 
has  degenerated  into  purf.  To  relieve  this,  the  hr^'  efforts  will  be 
made.     In  very  many  cases,  I  have  seen  the  besr  ^  Tects  result 


ERYSIPELATOUS    INFLAMMATION. 


171 


from  swathing  the  part  in  flannel  wrung  out  of  water  as  hot  as  can 
be  borne  by  the  hand.  It  is  a  sedative,  and  relaxing  to  the  over- 
distended  tissue.  Sometimes,  on  the  contrary,  the  heat  increases 
the  pain,  when  of  course  it  ought  at  once  to  be  discontinued. 
The  only  course  now  is  to  make  free  incisions  completely  through 
the  diseased  structures.  Let  them  be  short  cuts,  but  as  numerous 
as  may  be  necessary  to  secure  a  free  discharge  of  the  effused 
lymph,  or  pus — whatever  fluid  may  be  in  the  tissue.  Thereafter, 
hot  fomentations  will  do  good  service  by  alleviating  the  pain  due 
to  cutting,  and  by  promoting  the  escape  of  the  blood,  lymph,  and 
pus  in  the  part.  These  incisions  are  necessary,  to  save  ulceration 
and  sloughing.  No  matter  where  the  seat  of  the  disease,  the  knife 
must  be  used.  The  scar  resulting  will  not  be  so  unseemly  as  that 
deformity  which  would  otherwise  result,  not  to  speak  of  the  dan- 
ger to  which  the  life  would  be  exposed.  When  the  face  is  the 
seat  of  disease,  the  hesitation  to  use  the  knife  may  be  great ;  but 
it  must  not  be  forgotten,  that  when  the  swelling  subsides,  the 
wound  will  very  much  diminish,  so  as  to  very  materially  lessen 
the  scar. 

The  general  treatment  must  be  the  most  vigorous,  supporting 
the  strength  by  often  repeated  stimulants,  so  as  to  keep  the 
tongue  moist.  The  essence  of  beef  should  be  given  as  freely  as 
possible. 

The  other  forms  of  erysipelas  which  were  referred  to  do  not 
require  any  separate  notice,  in  this  work,  with  respect  to  treat- 
ment. In  every  case  the  disease  is  the  same,  only  that  in  some 
cases  the  constitutional  poison  is  more  active,  more  virulent ;  and 
that  in  some  individuals  the  constitutional  or  local  weakness 
causes  complications.  When  these  varieties  of  the  disease  present 
themselves,  the  treatment  will  be  modified  to  meet  the  require- 
ments of  the  case. 


I    I 


'a 


M;,y 


TDX^TSXOlSr     II. 


THE  HEALING  PROCESS,  AND  DISEASES  OF  THE  HEALING  PROCESS. 


CHAPTER    XX. 

The  Healing  Process,  Ordinary  and  Extraordinary  ;  Kepair  of  Tissue- 
Material  for  Repair — Fibrin. 

Perhaps  there  is  r  o  subject  in  the  whole  range  of  the  surgical 
science  which  can  supply  so  much  food  for  pleasant  thought,  in  its 
investigation,  as  the  healing  process.  .  Indeed,  the  surgical  science, 
I  venture  to  say,  is  based  upon  its  principles. 

In  the  course  of  our  examinations  of  the  phenomena  of  inflam- 
mation and  its  results,  we  have  caught  many  glimpses  of  the  ready 
efforts  of  nature  to  repair,  of  the  wise  steps  she  is  ever  taking  to 
secure  that  end,  and  of  the  varied  modes  by  which  she  brings 
forth  her  resources  for  its  accomplishment,  whenever  and  wherever 
they  may  be  required.  After  inflammatory  disease,  just  so  soon 
as  it  has  subsided,  and  physiological  action  can  supersede  the 
pathological,  the  simple  but  many-phased  operations  of  nature 
begin  to  display  their  wondrous  doings.  While  we  have  had  many 
glimpses,  now  and  then  we  have  had  clearer  views  of  her  all- 
suflicient  power. 

From  the  time  fibrin  begins  to  increase  in  quantity  and  vitality, 
aa  the  eff'ect  of  inflammatory  action,  and  the  dilating  capillaries 
begin  to  show  a  sacculated  condition — increasing  often  to  prolonga- 
tions—until healing  by  granulation  is  in  full  activity,  to  repair  a 
broad  or  deep  breach  (which  has  been  made  by  disease),  continued 
and  successful  eff"orts  to  heal  are  ever  manifested.  So  striking  are 
these  displays  during  what  is  generally  considered  only  a  morbid 
process,  that  the  thought  cannot  be  repressed  that  the  inflamma- 
tory process  should  be  regarded  rather  as  one  of  many  ways  to 
heal — that  it  is  a  first  and  necessary  step  to  the  attainment  of  a 
great  object.     In  other  words,  healthy  inflammatory  action  is  a 


THE    HEALING    PROCESS. 


173 


process  entered  upon  to  throw  off  a  morbid  material,  local  or 
general ;  or  to  prepare  a  way  to  expel  and  carry  off  a  foreign 
substance,  the  presence  of  which  is  inimical  to  the  health  of  the 
part,  and  which  precludes  the  possibility  of  restoring  the  part, 
which  has  departed  from  its  normal  condition. 

We  have  already  seen  {vide  Chapter  I),  and  it  is  a  well-known 
fact  in  physiology,  that  the  body  is  subject  to  incessant  decay ; 
that  every  tissue  of  the  body  is  mutable.  The  individual  parti- 
cles have  a  life  of  their  own,  which  is  very  brief  compared  to  the 
life  of  the  whole  body ;  and  this  life  may  be  shortened  by  use. 
This  never-ceasing  "wear  and  tear"  of  the  body  would  soon  un- 
dermine the  human  structure,  were  not  repair  as  constantly  taking 
place.  Thus  it  is,  that,  day  after  day,  ordinary  repair  is  made  in 
every  tissue  of  the  body.  Now,  it  would  seem  that  the  healing 
process  is  but  a  modification  of  ordinary  repair,  and  that  it  may 
be  designated  a  process  of  extraordinary  repair.  By  it,  nature 
displays  her  power  to  meet  the  varied  contingencies  which  wait 
upon  mortal  man.  There  is  not  only  ordinary  decay  of  tissue, 
but  there  is  from  time  to  time  a  more  palpable  destruction  of 
tissue. .  By  the  process  of  inflammation,  or  ulceration,  or  slough- 
ing, or  gangrene,  or  from  a  wound  or  mechanical  injury,  a  breach 
may  be  at  any  time  made.  While  such  destruction  is  uncertain 
as  to  frequency  and  extent,  yet  the  body  is  never  exempt  from 
danger ;  at  no  period  of  life  does  it  enjoy  immunity  from  these 
accidents.  And  for  the  well-being  of  the  'body,  for  its  preserva- 
tion, it  were  quite  necessary  that  preparation  should  have  been 
made  to  meet  the  wants  when  they  might  be  felt;  to  effect  extra- 
ordinary  repair,  when  there  should  occur  extraordinary  destruc- 
tion.    It  is  this  which  is  manifested  in  the  healing  process. 

Repair  in  Lower  Animals.— It  is  not  only  interesting,  but  in- 
structive, to  notice  the  fact  that  the  provision  to  restore  parts 
exists  in  the  lower  forms  of  animal  life  to  a  very  great  extent. 
It  has  been  fully  ascertained  (Paget)  that  this  extraordinary 
power  to  repair  is  exhibited  in  an  inverse  ratio  to  the  degree  of 
development  which  characterizes  the  animal.  That  is  to  say,  when 
much  strength  and  vitality  is  required  and  exhausted  in  the  de- 
velopment of  the  body,  there  will  be  a  corresponding  want  of 
power  to  effect  extraordinary  repair  when  called  upon  to  do  so. 
On  the  contrary,  when  the  powers  of  development  are  low,  there 


Mlij 


174 


PRINCIPLES    OP    SURaERT. 


'^ 


is,  to  some  extent,  a  compensation  in  the  ability  to  restore  lost 
parts.  Thus,  while  in  man  a  limb  may  not  be  restored  -when 
separated  from  the  bc^y,  the  hydra,  when  divided  into  many  parts, 
has  in  each  portion  the  pcvof  to  reproduce  all  the  parts  from  which 
it  has  been  separated.  Animals,  then,  whose  powers  of  develop- 
ment are  low,  and  which  are,  seemingly  as  a  consequence  of  that 
want,  more  exposed  to  injury  and  death,  have  supplied  to  them 
an  equivalent  by  which  death  and  extinction  of  the  species  are 
averted. 

The  ability  to  restore  is  in  man  comparatively  lim'ted.  la  the 
young,  however,  it  exists  in  a  much  higher  degree,  gradually  de- 
clining as  life  advances  and  growth  and  development  progress. 
The  less  the  power  which  has  been  expended  in  development,  the 
more  quickly  and  the  more  extensively  can  nature  do  repair.  So 
far  is  this  true,  that  the  child,  while  in  utero  (as  there  seems  to 
be  convincing  proof),  can  in  some  cases  have  restored  a  finger  or 
toe,  when  either  has  been  lost  by  intra-uterine  accident ;  a  power 
to  repair  never  known  in  the  child  after  birth.  Again,  cases  are 
recorded  where  a  whole  limb  has  been  amputated  in  utero ;  and 
although  not  altogether  restored,  there  was  found,  growing  from 
the  stump,  fingers  or  toes,  as  the  case  might  be.  And  it  is  a  fact 
of  great  practical  value,  that  in  childhood,  and  during  adolescence, 
the  healing  is  both  speedy  and  more  extensive ;  while  in  middle 
age,  and  especially  in  old  age,  the  process  is  often  tardj  and 
imperfect. 

It  was  thought  expedient  to  thus  call  to  mind  the  physiology  of 
ordinary  repair,  and  to  make  these  preliminary  remarks  relative 
to  the  subject  to  be  considered. 

The  Special  Agent  for  Repair. — We  may  now  proceed  to  dis- 
cuss the  question.  What  is  understood  by  the  Tloaling  Process? 
What  is  this  process,  by  which  restoration  is  sect,  red  and  '  ost  tissue 
regained  ?  Physiology  explains  to  us  the  process  of  ordinary  re- 
pair, called  nutrition ;  by  it  we  learn  that  the  blood  coursing 
through  every  part  of  the  body  washes  away  the  debris,  and  at 
the  same  time  supplies  the  necessary  elements  to  form  new  struc- 
tures. This  fact  furnishes  the  surgeon  with  light,  to  more  success- 
fully examine  the  method  by  which  healing  is  carried  on. 

Is  the  material  for  ordinary  repair  the  same  as  that  which  is 
demanded  for  extraordinary  repair  ?    In  the  first  steps  of  healing, 


i#-.-| 


THE    HEALINfJ    PROCESS. 


175 


the  material  seems  to  be  quite  dissimilar  from  that  appropriated  in 
nutrition,  although  derived  from  the  same  source.  It  is  from  the 
blood  that  is  obtained  the  great  primary  agent  employed  by  nature 
to  heal,  and  that  agent  is  undoubtedly  the  fibrin.  It  is  the  fibrin 
which  performs  this  most  important  duty,  second  only  in  import- 
ance to  nutrition  and  growth.  Whatever  other  purpose  the  fibrin 
may  serve,  this  is  the  principal  object,  seemingly,  for  which  it 
exists ;  and  it  is  a  function  sufficiently  high,  so  that  those  who 
have  been  wont  to  regard  fibrin  as  the  pabulum  of  the  tissues, 
have  no  reason  to  think  that  in  losing  that  status  it  has  sunk  into 
insignificance.  Can  it  be  thought  unlike  the  doings  of  nature  to 
suppose  that  she  specially  prepares  a  material  for  extraordinary 
repair— for  restoring  parts  more  palpably  destroyed?  Judging 
from  numerous  facts  and  data  in  the  possession  of  our  profession, 
one  does  not  hazard  much  in  venturing  the  opinion  that  this  is  the 
principal,  if  not  the  sole,  use  to  which  this  element  of  the  blood  is 
intended  to  be  put. 

This  view  has  forced  itself  upon  my  mind,  and  it  is  in  accord 
with  physiological  and  pathological  facts.     The  fibrin  is  an  ele- 
ment of  the  blood  which  primarily  was  capable  of  entering  into 
the  process  of  nutrition ;  but  not  being  required,  it  is  left  to  un- 
dergo a  change  by  which  it  is  made  to  occupy  a  grade  somewhat 
lower  in  the  scale  of  vitality.    We  cannot  suppose  that  the  supply 
of  food,  and  that  part  of  the  blood  which  is  the  most  highly  vital- 
ized, and  intended  for  the  nutrition  of  tissues,  will  always  be  just 
coequal  to  the  demand ;  nor  can  we  admit  that  the  supply  in  health 
is  ever  below  the  requirements  of  the  body.    Consequently,  we  may 
reasonably  suppose  that  there  is  often,  or  always,  found  in  the 
blood  of  the  body  more  material  for  nutrition  than  can  be  made 
use  of.     The  elements  of  the  blood,  like  the  tissues  of  the  body, 
have  their  day     F  growth,  development,  maturity,  decline,  and  of 
death.     When  the  tissue's  food  has  reached  its  highest  state  of 
vitality,  it  is  fitted  to  form  a  part  of  the  most  delicate  organ  in 
the  frame.    But  should  it  not  be  required,— and  we  have  seen  that 
m  all  probability  there  is  commonly  more  than  the  tissues  do  want, 
—then  degeneration  sets  in,  and  that  portion  will  have  passed  the 
meridian  of  its  life,  and  thenceforward  cannot  possibly  take  a  part 
in  ordinary  repair,  but  may,  if  required,  take  a  part  in  extraordi- 
nary repair.     Not,  it  is  true,  to  be  assimilated  to  the  tissue ;  but 


'■.11 


!tfi 


1 1 


I* 

V 


PI  i 

h 


176 


PRINCIPLES    OF    SURGERY. 


to  constitute  a  temporary  structure — a  scaffolding,  whereby  the 
permanent  and  the  natural  edifice  shall  be  built. 

I  would  liken  the  fibrin  to  refuse  timber,  which  can  always  be 
seen  strewn  about  a  building  in  the  process  of  erection.  It  has 
been  rejected,  not  only  because  better  were  available,  but  because 
other  and  enough  were  more  convenient.  This  material,  thus  de- 
clined, is  regarded  as  a  waste  substance,  and,  in  consequence  of 
its  being  thus  regarded,  is  subject  to  deterioration.  Now,  this 
timber,  which  has  failed  to  form  a  part  of  the  edifice  for  which  it 
was  prepared,  may  yet  discharge  an  important  duty  by  being  em- 
ployed to  construct  a  temporary  stage,  or  scaffold,  by  which  the 
permanent  structure  shall  be  completed.  So  the  fibrin.  Yester- 
day, under  another  form,  it  was  perhaps  qualified  to  enter  into  the 
formation  of  tissue.  To-day,  in  the  decline  of  life,  it  is  no  longer 
fit  to  accomplish  so  high  a  purpose ;  yet  not  so  degenerated  but  it 
may  answer  a  temporary  use  in  the  work  of  extraordinary  repair. 

Several  facts  seem  to  support  the  view  advanced ;  two  particu- 
larly :  first,  the  very  small  quantity  of  fibrin  in  the  blood  when 
the  body  is  in  a  state  of  health ;  second,  the  well-known  fact  that 
fibrin  increases  in  a  part  as  soon  as  the  inflammatory  process  com- 
mences— that  it  is  elaborated  in  excess  immediately  upon  a  pros- 
pect presenting  itself  of  it  being  required  to  restore  the  part. 
And  there  are  other  facts  which  serve  to  corroborate  the  theory, 
which  will  become  apparent  as  the  healing  process,  in  its  several 
forms,  is  duly  considered. 

We  have  seen  already  that  even  the  inflammatory  process  may 
be  looked  upon  as  a  means  to  secure  an  important  end, — the  heal- 
ing process.  But  when  inflammation  is  really  established,  what 
are  the  marks  by  which  we  can  trace  the  footsteps  of  nature  in  the 
great  work  of  healing  ?  An  early  product  of  the  inflammation  is 
liquor  sanguinis,  the  fibrin  of  which  stands  ready  to  commence  the 
work  of  repair  the  very  moment  an  opportunity  presents  itself; 
not  only  this,  but  its  presence  seems  to  do  much,  at  t'mes,  in  ar- 
resting the  disease.  The  serum  having  separated  from  the  fibrin, 
the  latter  begins  to  coagulate  and  to  contract.  By  this  means, 
the  tissue  in  which  the  inflammation  is  seated  becomes  fixed  to  a 
degree,  and  the  part  is  thereby  placed  in  a  state  of  rest,  so  essen- 
tial to  arrest  the  inflammatory  action,  and  to  allow  the  healing  to 
commence.     This  is  more  particularly  observed,  as  before  men- 


ilili 


FIVE    METHODS    OF    REPAIR. 


177 


tioned,  m  serous  membranes.     In  the  abdomen,  for  instance,  the 
viscera  constantly  moving  in  the  discharge  of  function,  or  under 
the  influence  of  disease,  will,  as  a  consequence  of  inflammatory 
adhesions   between   serous   layers,  become  fixed,  more   or  less 
thereby  arresting  the  morbid  action.     And  it  can  scarcely  be 
doubted  that  in  every  part  of  the  body,  when  the  fibrin  stiffens  in 
inflamed  tissue,  it,  by  securing  rest,  has  a  beneficial  effect,  although 
m  a  less  marked  degree.     Even  when  a  portion  of  fibrin  degene- 
i-ates  into  pus,  and  an  abscess  is  formed,  fibrin  will  be  found  around 
the  pus  in  a  coagulated  state,  so  as  to  form  a  barrier,  that  the  pus 
or  debns  may  not  enter  the  system.     And  if,  in  connection  with 
the  abscess,  an  artery  be  endangered,  the  fibrin  will  form  an  extra 
covering  or  coat  to  the  vessel,  to  preserve  the  coats  from  harm. 
And  should  the  process  of  ulceration  extend  to  the  arterial  tissue, 
and  the  tube  be  penetrated,  it  will  be  found  that,  before  this  could 
occur  the  artery  within  had  been  closed  by  a  plug  of  fibrin;  and 
thus  hemorrhage  is  averted.     When  we  come  to  consider  the  sub- 
ject  of  wounds,  it  will  be  seen  that  fibrin  is  the  effectual  agent  by 
which  a  divided  artery  is  permanently  closed;   and  likewise  in 
aneurisms  it  is  by  it  that  a  cure  must  be  made.    It  was  necessary 
to  thus  refer  to  these  several  modes  by  which  fibrin  is  known  to 
act  m  furthering  or  effecting  a  cure  in  inflammatory  disease.    We 
aj-e  now  prepared  to  examine  the  healing  process,  as  presented  in 
the  restoration  of  tissue  actually  and  palpably  destroyed 


mm 


CHAPTER   XXI. 

^7o^T^Vl  f  P^''"-I™'"«'i^^'^e  Union-Primary  Adhesion-Granula- 
tion-Second  Intention,  or  Second  Adhesion-Under  a  Scab,  CicatrizaSon 
-Requisites  for  Granulation.  '  ^'^''"^^a-io" 

According  to  Paget,  there  are  five  ways  by  which  the  healing 

may  ake  place;  but  we  shall  learn  that  each  is  a  modification  of 

he  others  and  that,  in  each,  fibrin  is  the  great  agent  by  which 

the  work  is  accomplished.  ^  b         y  wxucu 

12 


iv'^i 


178 


PRINCIPLES    OF    SURGERY. 


1.  Immediate  union.     2.  Primary  ad- 
4.  Second  ini.ntion,  or  secondary  ad- 


The  five  methods  are : 
hesion.     3.   Granulation, 
hesion.     5.    Under  a  scab. 

Immediate  union  may  take  place  between  the  surfaces  of  a 
wound  when  there  has  been  a  very  smooth  cut ;  when  the  tissue 
has  been  divided  by  the  sharpest  of  instruments ;  and  when  nei- 
ther bruising  nor  tearing  has  in  the  slightest  degree  attended  the 
wound.  If  a  part  thus  divided  be  immediately  placed  in  a  state  of 
absolute  rest,  the  bleeding  having  entirely  ceased  without  external 
aid,  and  the  surfaces  having  been  brought  accurately  together,  so 
that  each  tissue  sustains  the  same  relation  it  did  before  division, 
nerve  against  nerve,  vessel  against  vessel,  an  immediate  union  may 
take  place,  and  the  blood  very  soon  be  found  traversing  the  vessels 
which  had  been  severed.  There  will  be  no  perceptible  bond  of 
union  between  the  surfaces  thus  brought  and  retained  together. 
For  a  brief  time,  there  is  undoubtedly  a  stratum  of  fibrin ;  but, 
the  part  being  at  rest,  and  the  tissue  uninjured,  and  the  slight 
irritation  caused  by  the  cut  departed,  the  fibrin  is  not  required,  so 
that  before  it  can  become  solid  by  coagulation,  it  is  carried  away 
by  the  absorbents.  The  wound  is  rapidly  and  perfectly  healed. 
This  process  is  of  rare  occurrence ;  but  that  it  can  and  docs  now 
and  then  take  place,  there  is  no  doubt,  and  that  sometimes  exten- 
sively. The  following  case,  recorded  by  Paget,  is  instructive.  It 
is  of  "a  woman  thirty-three  years  old,  whose  breast  and  several 
axillary  glands  were  removed  for  cancer.  Iler  general  health 
seemed  good,  and  all  went  on  well  after  tiie  operation.  The  flaps, 
which  were  of  course  very  large,  had  been  cnrefuUy  laid  down, 
strapped  with  isinglass  plaster,  and  well  attended.  They  appeared 
to  unite  in  the  ordinary  way,  and  there  remained  only  a  narrow 
space  between  these  retracted  edges,  in  which  space  granulations 
arose  from  the  pectoral  muscle.  Three  weeks  after  the  operation, 
these  were  making  good  progress  toward  cicatrization  ;  but  erysi- 
pelas and  phlebitis  ensued,  and  the  patient  died  in  four  or  five 
days. 

'"  I  cut  off  the  edges  of  the  wound,  with  the  subjacent  partH, 
expecting  to  find  the  evidences  of  union  by  organized  lymjili,  or 
possibly  blood.  But  neither  c^  ""ited,  and  the  Htute  of  the  parts 
cannot  be  better  described  than  by  saying  that  scarcely  the  least 
indication  remained  of  either  the  place  vhere  the  flap  of  the  akin 


n 


FIVE    METHODS    OF    REPAIR. 


179 


was  laid  on  the  fascia,  or  the  means  by  which  they  were  united 
It  jas  not  possible  to  distinguish  the  relation  which  these  parts 
he  d  to  each  other  from  that  which  naturally  exists  between  sub- 
cutaneous  fat  and  the  fascia  beneath  it."  "  With  the  most  careful 
imcroscopic  examination,  I  could  discover  no  lymph  or  exudation- 
corpuscles  Now,  had  there  been  a  layer  of  organized  fibrin 
be  ween  the  surfaces,  it  could  not  possibly  have  been,  in  so  short 
a  tune  so  completely  removed.  We  are  by  this  case  enabled  to 
mfer  that  two  clean-cut  surfaces,  although  foreign  to  each  other, 
may  also  be  united  by  immediate  adhesion. 

When,  however,  the  essentials,  one  or  more,  for  immediate 
un.on  are  absent,  then  the  fibrin,  being  required,  forms  a  coating 
upon  the  surfaces  of  the  wound,  the  serum  having  trickled  away 
Under  these  circumstances,  the  wound  having  been  closed,  the 
glazed  surfaces  are  brought  in  contact  and  glued,  as  it  were,  to- 
getner;  and  thus,  union  by  adhesion,  or  primary  adhesion,  or 
mediate  umon,  as  it  may  be  called,  will  ensue.  The  interposed 
bond  of  union  may  be  thin,  or  it  may  be  thir  which  will  de^ 
pond  upon  the  degree  of  irritation  attending  the  wound 

But  sometimes  the  irritation  of  the  part  is  so  great,  and  of  so 
ong  duration,  that  more  fibrin  is  poured  out  upon  the  surfaces 
than  can  become  organized,  and  degeneration  of  at  least  a  portion 
-ets  in.     Shortly   the  wound  will  have  a  coating  of  pus,  the  inter- 
position of  which  precludes  the  possibility  of  primary  adhesion, 
^u  nature  ,n  no  way  disconcerted,  at  once  takes  a  different  step 
Although  the  wound  may  be  gaping,  and  pus  be  flowing  therefrom 
ye    beneath  the  pus  is  still  a  covering  of  lymph  recently  poured 
out.     a  he  irritation  having  ceased,  this  coa'ing  of  fibri.i  assumes 
the  work  of  repair.     It  is  converted  into  yranulations,  by  the 
successive  layens  of  which  the  cavity  may  be  expected  to  close. 
But  tins  work  of  healing  by  granulation  may  be  abbreviated,  very 
often,  by  bringing  the  granulating  surfaces  together,  and  thus  se- 
cunng  secondary  adhesion,  or  what  Hunter  called  union  by  second 
intention.  •' 

Healing  by  granulation,  and  subsequent  secondary  adhesion 
may  not  only  follow  a  wound,  but  also  after  destruction  of  tissuJ 
fjom^  mflammatiou,   or  from  any  other  cause.     {Vide  Healthy 

Again :  sometimes,  when 


part  to  be  healed  is  lim 


itcu  and 


II  "1 


180 


PRINCIPLES    OF    SURGERY. 


*  ii 


superficial,  a  portion  of  the  fibrin  upon  the  wound  will,  instead  of 
degenerating  into  pus,  become  dry,  so  as  to  form  a  crust  or  scab. 
This  crust  serves  to  protect  the  part  beneath  from  the  air  and 
other  irritating  substances,  and  thereby  allows  a  quiet  and  rapid 
formation  of  a  temporary  structure,  yet  approaching  in  character 
to  the  natural  structure.  In  this  case,  healing  is  procured  by  a 
species  of  growth  which  closely  resembles  the  healing  process  in 
the  cold-blooded  animals.  In  order  that  this  process  may  be  car- 
ried on  successfully,  it  is  necessary  that  the  serum  of  the  liquor 
sanguinis  should  have  a  free  way  of  escape,  if  it  be  not  absorbed, 
through  the  superimposed  scab ;  otherwise  it  will,  by  its  presence 
and  by  the  pressure,  interrupt  the  healing  process,  and  cause  quick 
degeneration  of  the  fibriu  into  pus,  constituting  an  acute  abscess. 
Familiar  instances  of  this  may  often  be  seen  when  the  skin  has 
been  torn  off  the  hand,  and  a  scab  has  formed. 

In  every  one  of  the  foregoing  processes  of  healing,  we  have 
seen  the  fibrin  acting  a  primary  and  principal  part,  and  that  it 
coagulates  and  becomes  organized.  It  now  becomes  necessary  to 
consider  what  is  understood  by  this  term ;  to  understand  to  what 
extent  fibrin  can  and  does,  under  favorable  circumstances,  become 
an  organized  structure,  and  the  manner  in  which  it  is  accom- 
plished. 

Organization  of  Fibrin. — The  power  of  fibrin  to  become  organ- 
ized has,  with  a  show  of  good  reason,  been  disputed.  But  tliat  it 
possesses  a  degree  of  vitality,  there  can  be  no  doubt.  It  will  be 
remembered  that  fibrin  consists  of  two  elements:  a  fibi incus,  and 
a  corpuscular  element.  Now,  when  fibrin  separates  from  the  blood 
and  is  placed  upon  the  surface  of  a  part  about  to  be  healed,  we 
find  certain  changes  taking  place  in  the  constituents.  The  cor- 
puscles manifest  a  tendency  to  develop  themselves — to  grow. 
The  shape  becomes  elongated,  and  sometimes  they  have  a  caudate 
form,  or  spheroidal  shape.  (Paget.)  At  the  same  time,  the  fibrin- 
ous portion  exhibits  a  power  to  take  on  the  form  of  fibrinous  tinsuc, 
the  cells  being  interspersed  through  the  fibres.  Tlie  degri'o  of 
vitolity  shown  by  fibrin  in  thus  coagulating  will  be  found  to  vary. 

It  is  neccHsary  hero  to  call  to  mind  some  facts  dwelt  uixtii  in 
connection  with  the  inflammatory  process.  Fibrin,  when  removed 
from  the  body,  sooner  or  later  shows  a  disposition  to  coagulate ; 
and  this  is  properly  considered  the  last  act  of  life.    It  is  truly  the 


FIVE    METHODS    OP    BEPAIK. 


181 


yorrnoHu,  of  the  blood.  (Simon.)  Now,  when  the  same 
takes  place  m  the  fibrm  upon  a  wound,  it  is  also,  to  a  certain  ex- 
tent,  the  last  act  of  life_so  far,  at  least,  as  the  fibrin  itself  is 


e    of  viWlt  f  °'  •""  *"  "''''''^'"«  «^™  --•™'  ap- 

plies of  vital.ty  from  another  source,  death  and  disintegration 

wo„  d  very  soon  ensue.     But  in  the  successful  accomplishmen    of 

tic    eal,ngproe.,s,  ,t  does  obtain  support  from  another  sou  ce 

wh,ch  source  ,s  the  blood  itself.    To  have  a  supply  of  blood  toTe 

advc„t.„ous  m.ner,  it  i,  necessary  to  have  bloodvessels  in    h 

tracture,  by  wh.ch  the  blood  „,ay  circulate.    It  is  necessary  h  re 

0  aga,„  call  to  m,nd  the  fact,  that  in  active  congestion  the  vesse 

be  ome  e  ongated  and  sacclated;  and  that  when  inflammation 

follows,  those  sacculated  portion,  increase,  until  they  are  pro! 

by  which  the  fibrin- 
ous glazing  upon  the 
surface  of  the  wound, 
ns  it  is  coagulating, 
provided      witii 


18 


blood  voHsols.  Those 
ciipillary  offshoots 
reach  here  and  there 
into  the  coagulating 
^ubHtanco  and  finally  unite  together  to  constitute  a  network,  as  in 

surfaces  of  a  wound  .s  supplied  with  bloo,l,  by  which  vitality 

m 


f  XT     la 


^m 

Bi     1 

■Pffi  ' 

w.% 

t 

''    ,'    i 

M 

1 

1 

■ 

'=3  1  ». 

I      '            ' 

4-1 

iiii 

f, 


'li 


Uli 


1 1 


§. 


[jji,.  4    IP 


182 


PRINCIPLES    OP    SURGERY. 


sustained  in  the  adventitious  matter — the  temporary  structure; 
and  by  which  the  permanent  tissue  is  to  be  built  up.  The  same 
process  takes  place  as  well  in  other  forms  of  healing,  whether 

in  secondary  adhe- 
sion or  in  granula- 
tion. Wherever  the 
fibrin  is  effused,  there 
will  be  exhibited  the 
same  phenomena. 
The  vessels  are  seem- 
ingly always  formed 
,  in  the  same  way. 

Now,  the  adventitious  matter,  thus  provided  with  bloodvessels, 
becomes  thereby  elevated  toward  the  standard  cf  true  tissue ;  yet 
it  is  in  one  respect  essentially  and  distinctly  beiow  it.  It  is  want- 
ing, at  least,  in  one  grand  characteristic  of  the  natural  tissues  of 

the  body :  it  cannot  assi- 
milate to  itself  elements 
from  the  blood,  by  which 
its  existence  shall  be  per- 
petuated. The  natural 
tissues,  as  we  have 
learned,  enjoy  the  power 
of  begetting  tissue  like 
unto  themselves,  by  which 
ordinary  repair  is  con- 
stantly made,  and,  not- 
withstanding the  w(?ar  and 
tear,  by  which  the  inte- 
grity of  the  part  is  stea- 
dily niaintiiined.  But  this 
pseudo-tissue  has  no  3uch 
power ;  at  loast,  if  it  has,  it  is  in  the  most  limited  degree.  If 
therefore  follows  that  this  new  substance  is  doomed  to  polish ;  that 
its  constituent  elements,  as  they  die  one  after  another,  having  lived 
their  period  of  life,  leave  no  similar  elements  to  take  their  [daoo. 
In  other  words,  there  is  not  nutrition  of  the  adventitious  tissue. 
While  it  resembles  ordinary  tissue  in  being  subject  to  wear  anil 
tear,  it  cannot  perpetuate  itself.     Particle  after  particle  perishes. 


FIVE    METHODS    OF    REPAIR 


183 

and  is  removed  by  the  absorbents,  until  in  the  lapse  of  time  it  en- 
tirely  disappears  And  while  this  want  of  power  to  beget  tissue 
IS  manifested  in  the  pseudo-tissue,  the  natural  tissue,  in  4ich  it  is 
placed,  displays  that  power  to  an  exalted  degree;  so  that,  a.  the 
false  parishes  and  is  removed,  the  true  takes  its  place.  In  this 
way,  the  substance  which,  for  a  time,  occupied  the  place  of  natural 
tissue,  IS  gradually  removed  by  nature,  and  the  natural  tissue  is  as 
gradually  restored. 

In  some  cases,  the  process  is  carried  on  very  slowly.  Much 
will  depend  upon  the  age  of  the  individual.  The  younger  he  is 
the  more  rapidly  will  the  work  be  accomplished.  Even  a  lar.e 
cicatrix  IS  sometimes  gradi^ally  removed  in  the  young.  At  first 
prominent  and  unseemly,  it,  as  .onths  and  years  roll  away,  per- 
ceptibly  diminishes,  until  finally  it  fades.  Sometimes  the  scar  is 
so  large  that  a  lifetime  is  not  suflicient  to  elFect  the  extinction  :  yet 
It  IS  ever  decreasing.  ^ 

Healthy  Ulcer.-ln  many  cases,  the  fibrin  is  thrown  out  so 
rapidly  and  in  such  large  quantities,  that  it  fails  to  become  or- 
ganized.    It  coagulates,   but  bloodvessels  are  not  formed  within 
It,  and  consequently  its  existence  must  be  a  brief  one'.     It  will 
very  soon  degenerate,  or  actually  perish.     More  generally,  the 
n-ntation  leads  to  this  effusion,  and  it,  failing  to  organize,  dLne- 
rates  into  pus^    Under  circumstances  favJJ-able  t'o  heaiingM 
whole  of    ho  effused  fibrin  will  not  degenerate  into  pus ;  whU;  the 
outer  portion  will  thus  degenerate,  that  which  is  immed/ately  upon 
.0  tissue  may  be  undergoing  development.     Not  unfrequenUy, 
to  irrita  ion  which  led  to  the  large  quantity  of  effusion  was  th^ 
m,  or  perhaps  other  substances,  coming  in  contact  with  the  wound 
In  such  cases,  tlie  pus  becomes  an  a.  ^tant  in  effecting  repair.     It 
constitutes  a  covering,  by  which  .     air  and  other  irritating  sub. 
stances  are  kept  from  the  sensitive  healing  surface 

inder  the  covering  of  the  bland  pus  is  a  layer  of  fibrin,  under- 
going  changes  similar  to  those  wi.ich  we  have  traced  in  adhesion. 
''^>  f'l-nn  eonguh,tc-s  ar.d  contract;  but  it  will  be  found  that  it 
•loos  not  evenly  cover  t!.e  surface.  In  contracting,  it  has  taken 
I  -e  toward  mu.y  .nitres,  so  as  to  give  rise  to  little  elevations^ 
jwth^^intervening  depressions.     In  this   way  are  formed  granZ 

Into  each  of  tliese  little  bodies  will  soon  bo  extended  n.anill„r- 


\ '' .  u 


i    !    J 


i!:: 


184 


PRINCIPLES    OF    SURGERY. 


vessels ;  and  in  a  short  time,  veins,  and  arteries,  and  nerves  are 
developed.  The  presence  of  nerves  has  never  been  discovered ; 
yet  the  extreme  sensitiveness  with  which  they  are  endowed  indi- 
cates the  existence  of  nerve-matter.  Certainly,  they  are  under 
the  influence  of  the  nerves,  although  one  may  not  actually  exist 
in  the  granulation. 

The  phenomena  of  life  is  exhibited  in  granulations.  They  grow, 
undergo  gradual  development,  and,  having  reached  a  certain  stand- 
ard, they  become  the  base  for  a  second  layer  of  granulations, 
which  will  be  formed  in  the  same  way  and  developed  by  the  same 
means,  to  be  followed  by  successive  layers.  Thus,. in  time,  the 
breach  is  entirely  filled.  As  each  successive  layer  is  formed,  its 
area  is  somewhat  diminished,  so  that,  as  the  healing  sore  comes  to 
the  surface,  it  is  gradually  lessening  in  diameter.  This  is  due  to 
a  general  contraction  at  the  base  of  the  ulcer  as  the  healing  pro- 
gresses. There  are  a  variety  of  circumstances  which  may  jxiodify 
the  healthy  granulation,  and  shorten  or  lengthen  the  time  neces- 
sary for  its  accomplishment. 

Cicatrization. — As,  in  the  process  of  granulation,  the  surface  of 
the  sore  approaches  to  a  level  of  the  integument,  cicatrization 
commences.  At  the  margin  of  the  sore  will  be  seen  a  bluish- 
white  pellicle,  gradually  extending  toward  the  centre.  It  is  gra- 
dually developed  into  a  pseudo-integument,  to  be  in  the  course  of 
time  replaced  by  the  natural.  This  cicatrization  always  com- 
mences and  progresses  from  the  circumference  to  the  centre,  until 
the  whole  of  the  granulating  surface  is  covered,  when  cicatrization 
is  complete.  However  large  the  sore,  the  process  is  always  the 
same.  Sometimes  the  covering  will  be  seen  to  be  simultaneously 
forming,  from  one  or  more  points,  islands  in  the  central  part  of 
the  sore ;  but  it  will  be  found,  upon  close  examination,  that  in 
these  places  had  been  minute  portions  of  the  original  skin,  from 
which  cicatrization  could  commence. 

Esicntiah  for  Healing. — That  the  healing  by  granulation  may 
commence  and  be  consummated,  it  is  necessary  that  there  be  not 
undue  irritation.  Inflammatory  action  must  have  entirely  ceased. 
It  has  been  shown,  that  in  a  given  cape  of  wound,  a  slight  increase 
of  irritation  may  completely  arrest  the  union  by  adhesion,  and 
render  necessary  the  more  complicated  process  of  healing  by 
granulation.     Now,  a  still  greater  degree  of  irritation  will  disturb 


ULCERS. 


185 


the  process,  w  that  healing  „»n„„t  at  all  take  plaee,  and  perhao, 
convert  the  part  .nto  a  state  of  ulcerative  inL«™&?   it  ^ 

moved ,    ha   the  blood  m  the  systen,  and  in  the  part  should  be  in 
a  phys,o  og,cal  condition.    The  part,  at  least,  !houId  be  stead 
fast ly  retamed  in  a  state  of  «,,  the  air  and  other  rritantset 

Somet,mes  the  above  .eqnirements,  however,  are  not  met     Na- 

proceed.  In  o  her  words,  there  may  be  a  dueme  of  the  hcalina 
process,  prcsent.ng  to  the  surgeon  some  one  of  the  manyform  7f 
ulcers,  or  sores,  which  he  is  called  upon  to  treat. 


Ulcers  --i)e..a,,,  ,/  the  muling  Process. -Vhovs  may  be  di- 
vided  mto  two  general  kinds,  the  health,  and  the  unhealtli 

hnolH         .       f^   ''^''''  ''P*^^'  ^'^  '^''''^^  ""d^r  the  rules  of 
healthy  action,  by  granulation,  the  process  described  in  the  pre- 
ceding chapter      The  time  occupied  is  not  prolonged;  the  par 
when  repaired,  is  stable.  ^     '  ^      ' 

The  unhealthy  ulcer  is  one  in  which  restoration  fails  to  be  ac- 
complished in  the  proper  time,  and  in  a  stable  manner 
J^^sesof  Unhealthy  Ulcers.-The  cause  of  failure  to  heal  may 
exist  in  the  constitution,  or  it  may  reside  only  in  the  part. 

Local  Causes.~l  will  speak  first  of  the  latter,  where,  owing  to 

tain ;      M^  ,    '  ^'"'"^  ""^  ^'  ^'"''''y-     I*  -":-  ^^  ^om-  irri- 
tttt  on  ^.hich  leads  to  excessive  determination  of  Idood,  and  inflam- 

-  ovy  action.     Perhaps  there  is  not  the  necessary  'state  ofrel 

I      part  whereupon  the  ulcer  is  situated  is  made  to  move,  as  upon 

a  Innb;  or,  as  often  is  seen,  the  function  of  the  part  keeps  u{f  a. 


I 


•m 


If* 
uV.  < 


i:^  ^1 


',1^. 


''115 


186 


PRINCIPLES    OF    SURGERY. 


much  motion  as  will  prevent  the  healing  process.    ( Vide  Fistulse.) 
Improper  position  of  the  part,  by  which  free  circulation  of  the 
blood  in  the  part  is  more  or  less  interrupted,  tending  to  venom 
congestion.     The  venous  blood,  which  fills  the  dilated  capillaries, 
cannot  supply  the  elements  necessary  for  healing.      Improper 
dressing  to  the  wound  is  another  frequent  cause  of  delay  in  heal- 
ing, very  often  converting  a  healthy  sore  into  an  unhealthy  one. 
It  is  so  very  difficult  to  disseminate  the  true  and  simple  principles 
upon  which  the  process  of  healing  is  based,  not  only  among  the 
public  generally,  but  also  among  the  members  of  the  profession ; 
and  the  fault,  it  must  be  admitted,  lies  at  the  door  of  the  writers 
and  teachers  of  surgery.     If  it  could  be  fully  understood  that 
healing  is  alone  the  work  of  nature,  and  that  to  do  her  work  she 
only  asks  to  be  let  alone,  and  not  to  have  the  part  placed  in  a  state 
unlike  the  natural.     Calling  to  mind  the  old  but  beautiful  quota- 
tion, that  "nature  when  unadorned  is  adorned  the  most,"  I  would 
apply  it  here  by  saying  that  when  a  part  to  be  healed  is  in  a  state 
of  health,  nature  is  most  assisted  when  let  alone. 

A  healthy  sore  requires  nothing  but  protection  from  the  air  and 
other  objects  of  irritation,  and  to  be  kept  moist  and  clean.     Yet 
often  will  numerous  bandages  be  applied,  and  the  part  will  become 
heated  and  irritated  by  the  discharge,  which  is  not  allowed  to 
escape.     There  is  always,  in  healthy  granulation,  more  or  less  of 
serum  escaping ;  and  this,  pent  up  in  the  hea4;ed  bandage,  under- 
goes decomposition,  forming  a  further  source  of  irritation.    Clean- 
liness, so  important  a  consideration,  is  impossible  under  such  cir- 
cumstances.   Again,  the  application  of  ointments  to  healthy  sores 
is  a  very  common  thing.     Occasionally,  pure  lard  may  protect  a 
sore  from  irritation  ;  but  it  is  absolutely  necessary  to  thoroughly 
remove  it  by  soap  and  water  once  a  day,  otherwise  it  is  sure  to 
become  an  irritant.     Often  the  lard,  or  the  simple  cerate,  is  im- 
pure, and,  almost  from  the  first,  causes  irritation.    But  even  when 
it  is  not  impure,  it  soon  becomes  admixed  with  the  discharge  from 
the  sore,  and  very  likely  leads  to  chemical  combinations  which 
prove  highly  irritating  to  the  sore  and  the  tissue  around.    Although 
now  and  then  unguents  may  serve  to  protect  the  sore,  they  should 
be  strictly  confined  to  the  sore  itself;  for  if  the  intognmcnt  around 
is  besmeared,  it  will  be  impaired  in  respect  to  function,  and  will 
not  constitute  a  sound  base  from  which  shall  grow  and  develop 


ULCERS. 


187 


'.! 


he  g™„lat,o„8.  Again,  a  healthy  sore  may  beeome  unhealthy 
fron,  ,„kerent  ^eakneu  of  He  part  whereon  ft  is  located  or  the 
part  „ay  beeome  diseased  from  the  contact  of  .„™.  rnZhVml 
nal,  m  eonsequenee  of  which  the  tissue  which  forms  the  baT  , 

capabk  of  supplying,  by  assimilation,  those  element    from  Ae 

tiolf'anlr  """  ''  """"^  ™'°  ""  "*«-*'  f™"  ">»  f°™a. 

urn  „rtheT  °""  °''"  "-^  ^"f""^  »■''■»''  »"«■>-  the 

seium  of  the  hquor  sangn.n.s  that  woald  trickle  away.     Its  nre 

one  "Ind°"  ""?  "■'  '■'"""«•  ""<•  "■"'"-  »"  ">»'  had  been 
done.    And  agam,  a  fcaS%  sore  u  ,on^time>  changed  into  an  in 
Pnmatory  „„.,  by  the  presence  of  the  trunk  of  a  nerve  upo!  Z 
surface,  or  very  npnr  in  Jf     Tf  rv,      u  P      "^ 

are  involved      Th..  ^     '  ""■""■""'  P^'-ipl'ory  ndrves 

are  involved.     The  consequence  is,  very  great  irritation   and  in 

flammatory  action  of  a  persisting  kind 

CbK,«««W  Came,  of  mease  in  the  Sealing  Process  -Such 

diseases  as  vtt.ate  either  the  tissues  or  the  blood  will    f  L  inter 
fere  w.th  healthy  healing.     Any  general  weakness,  her  dUa  v  or 
acqu,red-an  impoverished  condition  of  the  blood,  due  to      e. ul! 
hvmg  or  bad  food-may  suffice.     The  constitution  ,krngd1™m 
any  cause,  ,f  a  solution  of  continuity  occurs,  from  injury   or  in 
llammation,  or  destruction,  the  process  of  healing  cannof 'ensue  • 
or  If  It  do,  the  work  will  be  but  slowly  and  imperfltlv  pi  formed' 
Again,  there  are  certain  diatheses,  which  not  only  giVe  eha>™ L; 
0  ulcers,  but  are  also  frequently  the  eanse  of  the  ule r.     As  1  „" 
been  elsewhere  explained,  tuberculous  deposit  and  syphilitic  p'ion 

cause.    Afte.  the  local  manifestation  of  the  disease     n  attemnt  is 
mJe  to  repair;  but,  the  blood  being  deficient  in  vital  f";?i 

nothmg  besules  protection  from  irritating  substances,  aLl  ,luca- 


ia 


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188 


PRINCIPLES    OF    SURGERY. 


tion  to  cleanliness,  with  continued  rest.  Simpk  water-dressing  is 
the  best  application.  The  water  should  be  neither  hot  nor  cold. 
A  fold  of  cotton,  dipped  in  tepid  water  and  gently  applied,  is  suf- 
ficient to  protect  the  part ;  that  is  to  say,  the  cloth  preserves  the 
covering  of  pus  upon  the  sore,  which  is  the  natural  protection. 
And  this  pus  should  never  be  removed.  The  sore  must  be  kept 
clean  ;  but  by  this  is  meant  the  integument  around  the  ulcer.  The 
pus  must  never  be  wiped  off  the  granulating  surface,  as  may  be 
often  seen  done. 

The  constitution  is  not  in  any  way  aifected,  and  therefore  re- 
quires no  attention ;  unless  it  be  to  preserve  the  sti-ength,  under 
increased  demands  upon  it. 

Treatment  of  Unhealthy/  Ulcers. — The  first  thing  is  to  possess 
a  distinct  knowledge  of  the  cause ;  to  comprehend  exactly  why  the 
ulcer  does  not  heal ;  whether  the  cause  is  local  or  constitutional, 
or  both.  Then  let  the  surgeon's  efforts  be  directed  to  effect  its 
removal. 

A  sore  that  is  filthy,  and  irritated  from  bandages  and  retained 
discharge,  ought  to  be  thoroughly  cleaned  with  Castile  soap  and 
water,  to  be  repeated  at  least  once  a  day :  an  advice  which  it 
might  seem  superfluous  to  give ;  but,  on  the  part  of  many,  there 
is  such  a  forgetfulness  with  regard  to  this,  or  an  antipathy  to  it, 
that  it  is  very  often,  according  to  my  own  experience,  neglected. 
The  bandages  should  not  be  used  a  second  time,  but  burned  when 
removed.  The  part  must  be  kept  in  a  state  of  rest,  and  in  such  a 
position  as  will  allow  free  circulation  of  blood.  Attention  to  posi- 
tion will  be  more  important  when  there  is  a  tendency  to  venous 
congestion,  and,  as  a  consequence  of  it,  a  weak  or  indolent  sore. 
In  the  weak  ulcer,  where  the  veins  are  dilated,  decided  benefit 
will  often  be  derived  from  the  use  of  adhesive  straps  and  band- 
ages, by  which  external  support  is  given  to  the  vessels,  and  thus 
arterial  circulation  be  favored.  This  is  the  great  desideratum  in 
the  tveak  sore  :  to  procure  pure  blood  ;  to  have  it  circulating  freely 
in  the  part.  If  the  blood  itself  is  deficient  in  Vitality,  of  course 
constitutional  remedies  will  be  required;  but  when  the  paucity  of 
blood  is  due  to  local  causes,  those  alone  will  demand  attention. 
In  the  weak  sore,  there  is  not  only  a  want  of  power  to  heal,  but, 
there  being  an  effort  to  repair,  the  result  of  the  effort  is  the  forma- 
tion of  granulations  which  are  destitute  of  vitality.     They  are 


ULCERS. 


189 


pale  and  tall,  instead  of  that  florid  -AnA  fi.rv, 

teristic  of  the  healthy     The  MT  u  ^PP^'^''^^^^  ^^'^'^<^- 

tut  aeaitny.    ihe  sore  is  perhaps  more  than  filled  with 

ment.  If  touched,  they  are  foand  to  be  quite  destitute  of  sensa 
.on,  and  are  soft  and  yielding.  The  probe  will  easily  broaVh™ 
down,  and  therefron,  venous  blood  will  freely  escape  Now  ,tv 
often  these  unperfect  g.anulations  cannot  be  developed  il!7 
ur,ng  ..ssue;  and  in  „a„y  cases,  when  it  is  aceolp  fshed  ,0"^ 
t.me  wUI  be  required  for  the  purpose.  Consequentlr  iUs  oftef 
necessary  to  destroy  the  mushroom  growth-this  JhiX  IT 
caned  "proud  flesh."    The  effort  may'bele  to  brl;  hrgrtu" 

lants,   but  this  fad.ng,  ,t  will  be  necessary  to  destrov  tb™  hi 
causfc  generally  the  Nitras  Argenti.    A  Liety  ofTtiluirti'j 

„t::r"Tb::b  T  '■^''°™™^^^.  - "-  for'™  „f  tr "  ■  t 

ointment.    The  objection  to  unguents,  before  advanced,  is  perbans 

:  rir:,.:;:::  i  rrs:;:^^  ^.^.  --'  *■ " 

.0  use  them  in  the  form  7ZCt:^2  Z^ 
ommonly  ,„  „se  I  have  to  mention  one  particularly,  wliici  i    " 
found  exceedingly  useful.    It  is  a  lotion  of  belladonna,   led  bv 
water  and  the  extract.    In  some  cases  of  obstinate  weak  and  in 
iklent  ulcers  of  the  leg,  I  have  succeeded  in  healing  the  soi-ttf 
everything  else  had  failed.    The  lotion  was  appliedln'he  mli:/ 
and  then  a  bandage  applied  to  the  limb.     When  the  caustic  r^!' 
sorted  to,  it  must  be  used  sufficiently  to  destroy  h    whokor  1  le" 
morbid  growth.     Often,  after  the  caustic,  a  poultice  wi  1  be  r^ 
quired  to  assist  the  process  of  separatio^  of  the  e^U        Tl I" 
being  accomplished,  it  may  be  expected  that  healthy triin,  w 
commence  from  the  bottom  of  the  ,or»      nf  neo'ing  will 

the  previous  weak  g^ulattfrnrhav^  bTerrro^r"'!:' 
blood  must  be  in  a  normal  state,  and  properly  supp "ed  .   t t  pL. 

The  Mniulcr  requires  nearly  the  same  treatment  as  the 


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PRINCIPLKS    OF    SURGERY. 


week  after  week,  with  little  or  no  variation.  The  bottom  of  the 
sore  will  present  a  coating  of  an  ashy  hue,  which  will  have  little 
or  no  sensation.  Sometimes  it  will  be  sensitive  in  places.  The 
margin  is  of  a  pale  blue  color,  and  often  inverted,  making  the  sore 
look  as  if  the  skin  had  been  cut  out  with  a  stamp.  This  sore  re- 
quires the  same  treatment  as  the  weak  kind,  with  this  difference : 
that  in  the  indolent,  stimulating  applications  are  more  frequently 
of  service  than  the  caustic.  There  are  no  sickly  granulations  to 
be  destroyed ;  but  sometimes  it  is  necessary  to  destroy  the  base  of 
the  ulcer,  the  tissue  being  so  morbid  in  its  nature  as  to  be  incapa- 
ble of  begetting  any  granulation  at  all.  It  is  in  this  kind  of  ulcer 
that  I  have  used  to  advantage  the  lotion  of  belladonna.  Some- 
times, in  the  leg,  just  above  the  ankle,  the  integument  around  the 
sore  is  altered  in  character.  Its  color  is  of  a  brownish  red ;  some- 
what shrunken,  yet  smooth  and  glistening.  The  skin  thus  affected 
may  extend  around  the  whole  limb.  The  part  probably  has  been 
in  that  state  for  years,  and,  if  injured,  is  incapable  of  healing.  It 
is  exceedingly  difficult  to  restore  it  to  its  natural  state.  Although 
the  sore  is  made  to  heal,  the  skin  obstinately  remains  the  same, 
and  the  sores  are  liable  to  return.  Attention  to  the  general 
health,  and  avoidance  of  whiskey — which  is  a  common  cause  of 
the  affection — and  also  attention  to  cleanliness  of  the  part,  may 
after  a  time  do  much  to  restore  the  part  to  health. 

The  irritable  ulcer  is  distressing.  It  is  caused  either  by  some 
irritating  application,  or  by  the  presence  of  nerves  upon  the  sur- 
face of  the  sore.  The  periphery  of  the  nerves,  morbidly  sensi- 
tive, keep  up  an  inordinate  flow  of  blood,  which  is  inimical  to  the 
healing  process.  The  nerves  can  be  easily  detected  by  passing  the 
probe  gently  over  the  surface  of  the  sore.  If  there  be  scattered 
over  it  the  periphery  of  the  nerves,  it  will  be  tender  to  the  touch 
in  every  part ;  and  if  it  be  the  trunk  of  a  single  nerve,  when  the 
probe  comes  to  it  there  will  be  a  sudden  flinching  by  the  patient. 
The  only  way  to  effect  a  cure  is  to  preserve  the  part  from  irritating 
applications,  and  apply  something  to  soothe.  Oftentimes  cold 
water  is  the  best.  VVhen  there  is  a  nerve,  or  there  are  numerous 
little  ones  distributed  over  the  part,  they  must  be  destro;  id. 
When  the  nerves  are  not  large,  a  solution  of  Nitras  Argenti  may 
be  sufficient,  or  the  solid  stick  may  be  necessary.  But  when  there 
is  a  single  trunk  causing  the  irritation,  Hilton  recommends  the 


i''"? 


ITLCERS. 


191 


contact  ot  a  rough  substance  upon  which  the  discharge  has  been 
Ilowed  to  remam.  Conjointly,  the  blood  is  often  in  a  gross  sta  o 
rom  .mperfect  food  or  intemperance.    I„  the  first  plafe  th    i^ 

hZoT  T  "r;"'^''-  ^" ''°  "■''' » '-d  >o/on  wi,  pro';; 

he  most  useful     Afterwards,  the  treatment  will  be  the  salll! 
that  recommended  for  the  irritable. 

The  ,crofulom  ulcer,  the  mphiUtk,  and  the  .hughma    have 
1«„  fnlly  c«ns,dered  elsewhere,    (rv,.  those  suhje'cts  Sspeo^ 

The  Plageienic  f^^osr.-This,  of  all  the  >ore>,  is  the  most  nro 

.f  ction  Of  the  par::::^,  b  t:^toTe:urs.%s 

.re  two  promment  causes.     1st.  The  constitution  is  commonlv  „ 
a  very  depraved  state,  from  privation,  exposure,  ^.0!  ::r,td 
nith.     ^d.  Some  poison,  an  mal  eenerallv  offpn  ^^^i-r,- 
in  contact  with  a  part,  perhaps  th'e  ^^J^Z'!!^^::.^^:, 

tion.     1  he  treatment  is  the  same  as  for  sloughing.  * 

*h;t^::l.' ,  ra:^^:2'rt:s*"  tt-'  '"^»^^  °' 

"ja'Jiieaiation.     J  he  sore  which  results  from 

neal,  but  rather  as  an  effort  to  eliminate  a  blood  poison.   (Simon  \ 
The  subject  more  properly  belongs  to  the  subject  of  tuj^r^ 

fertofl""™'       """  """  "^  '"«°«-  *•"  '^several 
(.soases  of  that  process;  and  while  it  will  become  the  dutv  of 
he  surgeon  to  restore  the  part  and  the  constitution  to  a  s,.^ 
a     'it      ""f  ""l'"  unnecessarily  meddlesome.     Helnot 


w 


111 


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i 


II  f 


jDX-^xaxojsr    XXX. 

EXTERNAL   INJURIES — CONTUSIONS   AND   WOUNDS. 

CHAPTER    XXIII. 

Contusions — Kesults — Treatment. 

Contusion. — By  this  is  understood  a  bruising  of  tissue,  pro- 
duced by  a  blow,  or  a  fall,  or  a  weight  upon  the  part  injured. 
The  effect  upon  the  tissue  may  be  very  slight,  or  it  may  be  so 
great  as  to  actually  crush  out  the  vitality.  The  part,  in  the  for- 
mer instance,  will  quickly  recover  its  vitality ;  in  the  latter,  it  will 
become  speedily  gangrenous.  Then,  conditions  ranging  between 
the  two  may  be  followed  by  inflammation,  ulceration,  or  sloughing. 
The  degree  of  injury  will  not  depend  altogether  upon  the  degree 
of  force  with  which  the  foreign  body  comes  in  contact  with  the 
tissue,  but  as  well  upon  the  nature  of  the  part  involved.  When  a 
part  struck  is  soft  and  yielding,  other  things  being  equal,  the  tissue 
will  not  be  so  much  injured  as  when  a  subjacent  bony  structure 
exists,  against  which  it  will  be  more  easily  crushed. 

The  coats  of  the  vessels,  especially  the  capillaries,  are  more  or 
less  injured,  and  a  rapid  transudation  takes  place  from  them. 
This  fluid  consists  of  serum,  fibrin,  and  the  coloring  matter  of  the 
blood.     The  corpuscles,  many  of  them,  are  broken  down ;  or  per- 
haps the  coats  are  so  lacerated  that  a  whole  corpuscle  can  pass 
through  the  coat.     It  is  this  effusion,  taking  place  so  quickly, 
which  gives  that  characteristic  appearance  called  ecchymosis.     If 
the  tissue  be  lax,  the  effusion  is  greater ;  as,  for  instance,  when  a 
blow  is  received  upon  the  eye.    In  this  case,  the  lax  tissue  around 
the  eye-socket  is  crushed  against  the  bone,  and  thereupon  we  have 
the  immediate  disagreeable  discoloration.     Consequently,  the  de- 
gree of  transudation  will  not  depend  upon  the  severity  of  the 
iiyury,  but  rather  the  laxity  of  the  tissue. 


CONTUSIONS. 


193 


The  m^mptoms  are  always  evident  and  characteristic.    The  diaa 
mm  IS  not  difficult ;  neither  is  the  prognosis.  ^' 

JiesuUs.--Discoloration.-.ms  will  persistently  remain  for  a 
long  time,  as   the   coloring  matter  of  the  blood  is  no"  easilC 
removed  by  the  absorbents.     When  the  vessels  are  to  n   andnu  e 
blood  IS  extravasated,  the  time  will  be  very  protracted  Lf!.  ^l 
sorption  is  accomplished.    The  blood  will  i^  '^^l^^^^^^^ 
or  partially  coagulate.    This  is  often  seen  at  the^c  rcuXence^^^^ 

The  result  „ay  finally  be  suppuration,  the  formation  of  an  aC' 
and  ulumate  discharge.    On  the  contrary,  a  species  of  orlizat  „n 

Treatment-Will  depend  upon  the  extent  of  injury  which  th. 

cover  Its  vitahty,  or  more  tardily   or  whether  if  •    Y^^^/^' 
nerish      THa  ^^L.  j  i        •' '        ^nether  it  is  doomed  to 

pensh.     Ihe  steps  pursued  by  nature  must  be  the  guide  for  th,. 

follow.  v^angrenej,  and  healing  may  be  expected  to 

In  slight  cases  of  contusion,  unless  upon  an  exposed  part  but 

httle  requires  to  be  done      Whpn  thaZ  ■         ^*P"^^«  P^",  but 

^  wc  uuiie,     vvnen  tnere  is  ecchvmosia  imnn  th^ 

-oved.     It  is  by  the  absorLts    hat  the  work  ™   bTdo   ' 
Above  all,  I  have  found  useful  the  tincture  of  arnica        d'  no'; 

do  somcthinaTn  r :     ^;'''''^'^'\  P'-essure  made  by  collodion  may 

Cold  water  may  sometimes  be  used  to  advantage,  but  it  mu«t  be 

13 


Mm 

ill 


194 


PRINCIPLES    OF    SURGERY. 


i 

i 


applied  with  extreme  caution.  The  tissue,  already  very  much  im- 
paired in  vitality  by  the  crushing,  may  easily  be  destroyed.  Its 
use  must  be  regulated  by  the  heat  and  pain  and  redness  in  the 
part.  If  either  or  all  of  those  be  present,  cold  will  be  useful  in 
preventing  inflammation.  Occasionally,  sweet  oil  will,  by  soften- 
ing  the  distended  tissue,  be  of  use ;  it  will  also  soothe  the  irritated 
nerves.  A  poultice,  applied  cold,  will  now  and  then  give  sensible 
relief ;  but  when  the  blood  begins  to  flow  inordinately  through  the 
part,  cold  astringents  must  be  substituted.  I  have,  while  writing 
this,  under  my  care  a  patient  with  a  crushed  hand.  It  was  caused 
by  being  caught  between  two  cars  in  the  eff"ort  to  couple  them. 
The  hand  was  caught  sidewise.  The  metacarpal  bones  were  all 
crowded  and  twisted  together,  and  the  hand  actually  burst  open  in 
the  palm.  The  treatment  has  consisted  in  the  diligent  application 
of  ice,  rolled  in  cotton,  and  careful  retention  of  the  limb  in  a  very 
elevated  position.     The  result  ha?  been  the  most  happy. 

When  extravasation  has  occurred,  and  a  clot  of  blood  exists 
which  produces  pain  and  is  likely  to  cause  inflammation,  it  may  be 
expedient  to  made  an  incision.  After  a  time,  the  clot  may  begin 
to  soften,  when  the  escape  will  be  easy,  and  thus  inflammation 
averted.  When  an  abscess  results,  it  will  be  treated  on  the  ordi- 
nary principles.  If  sloughing  or  gangrene  ensue,  the  treatment 
will  be  for  such. 


i  '1!      :'l 


CHAPTER    XXIV. 

Wound8-Deflnition-Cla88ification-The  several  Dangers  attending  Wounds 
-Incised  Wounds-Characteristics-Gaping-Hemorrhage-Artenal-Na- 

tural  Hcemostatics. 

YfovNBS.— Sudden  Solution  of  Continuity.— Definition.— kn 
injury  resulting  from  the  disturbance  of  the  physical  continuity  of 
tissue.  The  definition  given  by  Cooper  in  his  Surgical  Dictionary, 
and  which  is  generally  more  or  less  adhered  to,  is  as  follows :  "A 
wound  may  be  defined  to  be  a  recent  solution  of  continuity  m  tlic 
soft  parts,  suddenly  occasioned  by  external  causes,  and  generally 
attended  at  first  with  hemorrhage."     This  definition  is  objection- 


Hi  : 


^Lm^ 


WOUNDS. 

able ;  because  tbere  may  be  \inm,la  nf  ti„  v 

lage,  as  well  as  of  the  Io(tZT\  ""*  "'  ""  '^"■•«- 

n.ent,  as  a  sabre,  may  dvM  1  T"""''  "  """"^  m»tr„- 

Agai„,anaxe.  ^bebur  d  „^  hTle  ;1?  °""'  ""  ^^f' 
soft  structures,  but  the  bo™  as  well  T„  ;/'"*"«  "»'  """^  '^« 
structures  are  wounded  aH^as  the  softer  "  """'  ""  ''"■'" 

cause  division  of  a  tendon      A  f      '"'^'^^"f  taking  place,  may 

^eingaisp,„ed,ca„s::ttud^„,^r:f  ;i:"%t^^^^^^^^ 

ternal  causes  of  iniuries  whiVJi  rv,o     i.         ^  ^^^  ^^®  ^^' 

wounds  as  .ny  ot.ilZl'rXT/.itT  Xr"^'^  '^™1 
is  often  made  bv  the  s„r,,^n«       v.    """^®'^-     '^t'"  ^gam,  a  wound 

whStttiftioTr^-^^-^  -'^  ---'  ^''''=""'.  -0-  of 

or^et'^^  wtihThe'rol?:"  "V'^r'"  °'  *'  ™'™-« 
Secmd  DMmn.-Uto  specific  and  ™„.,^,„%. 

i»  wiib  fh:r„„7T:t!tetr™  "-r  rr  -^  *^  ^°^^ 

M,  of  the  „.*,  of  the  «::'•;:  """"*  "^  "-^  '--''  »f  '-e 

Fifth  i)i„«,„„._i„t„  open  and  mbcMancom.    fSvst  q„r„  •, 
-Oayr  of  Wouna,.-PrognoA  and  ijCJ-In  the'fi'  . 
place,  let  us  consider  the  degree  of  danri^TT  "'''" 

various  wounds,  and  the  source  of  1  T^  .  '™^  """"'* 
iiasnon.  and  ^ro,  J^^  ItJilfdetn  Tthe  «T,  "'"°"  "-^ 
the  >iu  of  the  Jcuni.  The  1  rl  ho  woun'l  ",  '  "''  "^^ 
the  greater  the  danger     2d  Vhl  J        T     '  "'"'"'"  '"'"^"'' 

of  the  .t^re  .ttw     S"  Zh      """  ""^  '"^  '"'^"'""- 

i»  «"nded,  as  the  Wt,  or  thetnrXT"  """""«  '"  ''^* 

,  "I   uie  lung,  the  danger  is  imminent. 


•  ■  t 


j 


196 


PRINCIPLES    OF    SURGERY. 


Again,  a  wound  of  the  throat  is  critical,  because  of  the  necessity 
of  using  the  part  for  breathing  and  deglutition.  5th.  Another 
source  of  danger  is  when  a  large  bloodvessel  is  divided.  If  the 
vessel  be  large,  death  may  be  the  immediate  consequence ;  or  if 
the  loss  of  blood  be  very  great,  the  evil  effects  may  be  lasting. 
6th.  The  kind  of  wound  modifies  the  danger.  If  a  wound  be 
bruised,  or  lacerated,  or  poisoned,  the  danger  is  much  increased. 
When  a  part  is,  with  the  wound,  affected  in  either  of  the  above 
ways,  nature  will  have  more  to  do  than  simply  to  repair,  as  in  the 
incised  form;  consequently,  the  danger  is  greater.  7th.  The 
danger  is  greater  when  the  constitution  is  suffering  from  any  mor- 
bid diathesis,  as  the  scrofulous  and  the  syphilitic.  8th.  In  the 
aged,  a  wound  is  more  likely  to  prove  serious  than  in  the  young. 

Immediate  cause  of  death  when  it  ensues.— When  death  ensues 
from  the  wound,  it  may  be  in  consequence  of  hemorrhage,  imme- 
diately taking  place,  or  some  time  after.  It  n.ay  also  be  from  an 
attack  of  tetanus;  also  of  erysipelas,  or  pi/emia.  It  should  be 
remembered  that  a  healthy  sore  may  be  the  channel  by  which  ery- 
sipelatous  poison,  especially,  may  be  introduced  to  the  system, 
through  the  use  of  a  contaminated  sponge,  or  the  unwashed  hand 
of  the  nurse  or  surgeon.  A  sponge  that  h  s  been  in  use  ought 
never  to  be  applied  to  a  fresh  wound.  Again,  death  may  be  due 
to  hectic  symptoms,  which,  after  a  time,  may  supervene  from  con- 
tinued discharge  and  irritation,  in  connection  with  loss  of  blood. 
Death  may  result  from  a  part  becoming  gangrenous.  The  tissue 
around  the  wound  may  have  been  injured,  and  may  subsequently 
die ;  or  a  part  may  have  been  cut  off  from  the  necessary  supply  of 
blood,  by  division  of  an  artery. 

In  considering  the  subject  of  wounds,  it  will  be  convenient  to 
take  the  first  of  the  several  classifications. 

Incised  Wound.— In  a  pure  case  of  this  kind,  the  tissue  is 
simply  divided  by  a  sharp  cutting  instrument,  the  tissue  around 
being  entirely  uninjured.  The  surface  of  the  wound  is  neither 
lacerated  nor  bruised :  it  is  barely  irritated.  The  instrument  had 
necessarily  possessed  a  thin  blade,  as  well  as  a  sharp  edge,  and  the 
least  possible  force  would  be  sufficient  to  cause  a  solution  of  con- 
tinuity.   This  is  the  simplest  kind— the  perfect  type  of  an  incised 

wound. 

A  wound  may  be  small  or  large.     It  may  be  extensive  super- 


WOUNDS. 


197 


fioially  or  deeply  penetrating.    Both  the  extent,  and  the  direction 

Titit  *:;::' '"'"^-'"''™^'''-p''-^-idr::: 

^^racteri^io  of  ,He  incUei  „ound,  .„  yam,  ,aping,  Umor. 
The  pain  experienced  from  an  incised  ™nd  is  of  a  smarting  or 

:  'rfirTtir  to  tt  °T'  '^  '"^  ■''""'"'^  °f  the  r:r 

to  the  air,  the  a,r  to  them  being  exceedingly  irritating.    The  irri- 
tation may  in  part  be  dne  to  the  instrument  itself  by  which X 

he  contact  of  air,  or  of  foreign  bodies.    The  more  bonntifuHT 

the  tissne  i,  supplied  with  nerves,  the  greater  will  be  the Z^  "^ 

ffWis  caused  by  the  contraction  of  muscles,  and  by' the 

natural  contractile  power  with  which  tissue  is  posses  ed.     Gap  ng 

s  always  present;  but  the  degree  will  depend,  not  upon  th 'con 

™n  '  ';ir       "'•""  P™"'^^"^  ""»■'  *^  -i-ction  of    he 
wound.     The  gaping  is  greater  when  the  cut  is  crosswise  of  the 

muscle,  and  less  where  it  is  parallel  with  the  fibres.     Th   dcepe 

the  wound  the  greater  the  gaping  may  be  expected  to  be.       ^ 

Ber^rrUge  may  come  from  an  artery,  or  vein,  or  from  capilla- 

divided  The  surgeon  must  distinguish  between  arterial  and 
venous  hemorrhage.  It  is  not  difBcult  to  do  so.  Blood  from  the 
artery  comes  m  spurts  at  each  contraction  of  the  heart  and  art/ 
ries-"^..  ..ft     ,.     Th,  „,„i^,  „„„^  .^       a  bright  rdbl; 

xygenated.  The  venous  blood,  on  the  contrary.  Issues  witTf 
steady  even  Sow,  and  presents  a  much  darker  hue 

frtertal  Bemorrhage.-It  will  bo  advantageous  to  remember 
t  in  discussing  this  subject,  we  shall  learn  the  nature  of  hemor 

fof    b   bT''™™"  '"^'™'  »P-'i«nMn  the  perrrm. 
ance  of  which,  the  surgeon  intentionally  divides  structures  of  the 

in t'cil's"  '::  ^  'T,n  "'  '"""^'  ""^  -  -P"'"'^-  and 

n  excisions.    Also  we  shall  learn  many  of  the  principles  reUtin^ 

e  aneurism.    Arterial  hemorrhage  is  the  mos'  dangerous  form^ 

I  It  come  from  several,  or  many  smaller  vessels,  it  will  proveleTs 

dfcl  to  control,  than  when  it  comes  from  a  ^e  vessef  H 

again,  the  surgeon,  to  properly  comprehend  what  steps  shall  b^ 

aten  to  arrest  the  bleeding,  must  carefully  examil  the  f  o     en! 

of  nature-must  learn  of  her  who  is  an  infallible  teacher  "^ 


>|.i   i 


if 


9 


Hi! 


198 


PRINCIPLES    OF    SURGERY. 


rm 


M 


ibJhB^hh^      I 

H 

'  1  ;'" 

I^^^^P 

^.!i.:.! 

I^^^^^^^H' 

, 

•ii  i 


Natural  Rcemostatics. — It  is  a  fact,  known  by  any  observer,  that 
in  many  cases,  hemorrhage,  which  at  first  seemed  fearful,  will  in  a 
short  time  be  effectually  arrested  by  nature  alone.  The  surgeon 
can  but  proffer  assistance — can  but  order  circumstances  which  will 
constitute,  so  to  speak,  a  starting-point  for  natural  operations. 
Any  one  who  has  seen  the  knife  in  the  hand  of  the  surgeon, 
dividing  the  tissues  in  the  performance  of  an  operation,  will  have 
observed  that  the  blood  at  first  came  rushing  copiously  forth,  but 
that  it  gradually  lessened,  until,  in  most  cases,  it  entirely  ceased 
to  flow.  One  minute,  it  would  seem  to  the  uninitiated,  that  the 
patient  was  bleeding  to  death ;  at  the  next  there  would  be  barely 
an  oozing.  The  mouths  of  the  vessels  from  which  the  blood  welled 
are  quite  closed.  Now,  by  what  means  was  this  accomplished  ? 
How  can  we  account  for  this  phenomenon? 

From  careful  investigation  it  is  found  that  there  are  several  im- 
portant steps  taken,  one  after  the  other,  but  in  quick  succession, 
the  result  of  which  is  the  stoppage  of  the  bleeding.  That  con- 
tractility of  tissue,  by  which  gaping  of  the  wound  is  produced, 
affects  the  arterial  coats,  in  common  with  the  other  tissues.  Un- 
der this  irritation  the  coats  both  contract  and  retract.  It  is  a 
rare  thing  to  see  fully  exposed  the  open  mouth  of  the  vessel, 
although  bright  red  blood  marks  the  spot;  and  the  reason  is,  that 
it  is  drawn  in  from  the  surface  of  the  wound — the  coats  retract. 
The  contraction  of  the  coats  will  lessen  the  size  of  the  vessel,  and 
in  very  many  cases  completely  close  the  mouth,  and  so  arrest  the 
hemorrhage.  This  is  favored  by  the  absence  of  that  pressure  from 
within,  which  is  regularly  made  by  the  ever-passing  stream  of 
blood.  Of  course  this  contraction  and  retraction  are  principally 
due  to  the  muscular  coat  by  which  the  artery  is  drawn  in  from  its 
sheath.  The  result  of  this  combined  action  of  contraction  and 
retraction  is  that  the  lips  of  the  open  vessel  are  drawn  in,  making 
it  seem  as  if  the  middle  coat  were  contracted  more  than  the  ex- 
ternal, and  the  internal  more  than  the  middle.  The  lips  of  the 
internal  coat  are  in  this  way  drawn  towards  each  other,  and  in 
smaller  vessels  actually  together,  thereby  stopping  the  flow  of 
blood.  When  the  coats  are  thus  brought  in  contact  they  unite 
by  adhesion,  and  thereby  accomplish  another  step  in  the  process 
of  natural  haemostatics.  But  when  the  contraction  is  not  sufficient 
to  close  the  vessel  completely,  the  object  may  be  attained  by 


WOUNDS. 


199 


further  aid,  which  nature,  prolific  in  means,  will  be  able  to  give 
Kemember  ijiat  the  vessel  is  drawn  from  its  sheath,  leaving  a 
space   which   is   quickly   occupied    by   blood   (with  perhaps   an 
excess  of  fibrin  in  it).     This  blood  will  soon  begin  to  coagulate 
and  contract,  and  this  ring  of  coagulating  blood  will,  in  a  cer- 
tain number  of  cases,  afford  sufficient  pressure  from  without  to 
complete  the  work  of  closing  the  vessel.     Sometimes  the  sheath  is 
drawn  away  from  the  vessel  by  the  contraction  of  the  tissue 
around,  in  which  case  the  space  between  it  and  the  vessel  is 
greater,  and  the  quantity  of  blood  to  coagulate  will  be  correspond- 
mgly  greater.     Not  only  will  this  clot  form  around  the  vessel,  but 
It  will  manifest  a  tendency  to  extend  over  the  mouth  of  the  vessel  • 
and.  If  the  blood  do  not  spurt  out  with  too  much  force,  this  will  be 
successfully  done;  and  thus  the  artery  will  be  sealed  with  a  clot 
of  blood  which  IS  quite  external.     But  when  the  artery  exceeds  a 
certain  size,  the  force  of  the  wave  of  blood  will  be  so  great  as  to 
prevent  the  formation  of  the  clot  over  the  mouth,  and  the  bleeding 
will  continue.     A  certain  length  of  time"  is  always  necessary  to 
determine  whether  nature  can  accomplish  the  work  or  not.     Here 
then  are  several  means  by  which  arterial  hemorrhage  is  at  first 
naturally  arrested :  First,  there  is  contraction  and  retraction  of 
the  arterial  coats,  which  tend  to  close  the  open  vessel;  then,  the 
space  between  the  vessel  and  sheath  is  occupied  by  coagulating 
blood,  which  by  external  pressure  will  further  the  process  already 
commenced ;  finally,  the  clot  of  blood  may  gradually  spread  over 
the  mouth  from  which  the  blood  was  spurting,  and  so  form  a  com- 
plete seal.     This  is  the  first  stage  in  the  process  of  natural  haemo- 
statics. 

These  steps,  although  admirable,  ar^  not  lasting;  yet  they  are 
of  sufficient  duration  to  enable  other  and  permanent  ones  to  be 
taken.     When  the  lips  of  the  inner  coat  are  in  contact,  adhesion 
will  take  place  between  them ;  it  is  immediate  union;   but  when 
the  hps  are  not  in  contact  their  surfaces  will  be  coated  with  fibrin 
which,  perhaps,  will  constitute  a  bond  of  union.     When,  however' 
the  outer  clot  of  blood  is  slowly  formed,  there  will  be,  when  the 
bleedmg  is  finally  arrested,  a  plug  of  fibrin  formed  in  the  orifice 
Now,  whatever  may  be  the  way  by  which  the  mouth  of  the  vessel 
IS  closed  there  will  immediately  follow  steps  for  organization  in 
the  fabrin.     And,  while  this  is  being  done  the  arterial  tube  will  be 


i 


w  ■ 


<.  ! 


^mmm^m 


M 


200 


PRINCIPLES    OP    SURGERY. 


gradually  filling  with  a  fibrinous  clot,  which  will  separate  from  the 
blood  coming  to  the  part.  This  plug  of  fibrin  will  form  along  the 
tube  as  far  as  the  first  branch  given  off  from  it.  It  will  fill  the 
vessel  at  the  point  where  it  is  divided,  but  will  taper  to  a  point, 
making  the  whole  cone-like  in  shape.  By  means  of  this  clot  the 
hemorrhage  is  effectually  and  permanently  arrested.  In  time,  the 
clot  of  blood,  which  acted  an  important  part  primarily,  is  detached, 
and  cast  off;  but  the  internal  clot  assumes  the  form  of  adventitious 
tissue,  perfectly  seals  the  wounded  vessel,  and,  finally  becoming 
amalgamated  with  the  arterial  coats,  there  remains  but  a  cord-like 
substance.  Thus  we  see  that  in  natural  haemostatics  fibrin  is  the 
necessary  agent  by  which  the  action  is  completed.  The  clot  in 
reality  constitutes  in  the  whole  length,  as  far  as  it  may  extend,  a 
bond  of  union  to  unite  surfaces  together.  When  it  has  served  its 
purpose  it  will  gradually  decay,  and  be  removed ;  and  so  will  the 
arterial  tissue  in  the  process  of  time.  This  is  the  second  and  last 
stage  in  the  process  of  haemostatics. 

In  order  that  the  above  described  procedure  may  be  commenced 
and  carried  on,  it  is  necessary  that  the  artery  be  not  too  large — 
that  the  blood  do  not  flow  into  the  part  with  too  much  force ;  be- 
cause the  rushing  blood  will  not  allow  coagulation  to  take  place  at 
the  orifice.  Under  such  circumstances,  it  will  be  for  the  surgeon 
to  give  the  assistance  which  art  places  at  his  disposal.  There  are 
two  things,  generally,  which  may  be  done,  or  attempted,  either  to 
place  something  against  the  vessel  as  a  substitute  for  the  external 
clot,  until  the  inner  clot  of  fibrin  can  have  formed ;  or  to  arrest 
or  diminish  the  current  of  blood  flowing  to  the  part,  with  the  ob- 
ject of  allowing  the  external  clot  to  form,  which  had  been  pre- 
vented by  the  force  of  the  regular  waves  of  blood.  And  this 
brings  me  to  speak  of  the  general  indications  in  the  treatment  of 
incised  wounds. 


TRKATMENT. 


201 


CHAPTER   XXV. 

.ion^  .nd  cold  water  applied  wi„.  ^a'S  ll    rTrarr; 
much  increase  the  irritatJnr,      t>    u         ,        .  ^'  ^^^^ 

unifo™  cold  i^r.^rZTtXv^n     ruJ^      '  ""'  "'"•  ^ 

;.ud  w..  L  J»^r;^lrlTctr "";f :„,"! 

■„  re™!  "'  """^'^  "^  ^  f°"»  "'  -"»"  «>»'h,  frequntly  dipped 

pressure,  either  agamst  the  open  mouth  (direct  pressure)  or  nnon 
the  arterj  above,  where,  in  its  course,'  it  can  be  convenient?; 


-  )  < 


i'   I 


if 


fflf 


202 


PRINCIPLES    OF    SURQBRr. 


*t 


!•» 


made  (indirect  pressure).  The  most  speedy  way  in  which  pressure 
may  be  made,  is  by  the  hand.  The  finger  may  be  thrust  into  the 
wound — as  it  often  is,  by  the  operating  surgeon,  when  a  gush  of 
blood  interrupts  the  proceedings — and  be  placed  directly  upon  the 
vessel,  the  warm  gushing  blood  being  his  guide.  Oftentimes,  the 
surgeon  will  be  sent  for,  in  hot  haste,  to  visit  one  who  has  been 
seriously  wounded — at  least,  the  bleeding  is  frightful.  The  sur- 
geon will,  in  such  cases,  be  called  upon  to  display  his  presence  of 
mind,  where  all  is  confusion;  and  his  skill,  when  all  eyes  are 
turned  to  him.  Numerous  bandages  will,  no  doubt,  have  been 
applied,  and  the  bleeding  may  have  ceased ;  but  the  bandages,  in 
every  case,  will  have  to  bo  removed,  that  the  vessel  or  vessels  may 
be  properly  secured.  If  there  be  no  bleeding,  all  arrangements 
should  be  made  before  the  bandages  are  touched ;  but  should  the 
arterial  blood  be  seen  streaming  through  them,  then  the  proper 
course  is  to  use  promptly  indirect  pressure,  if  it  be  possible ;  or 
to  tear  the  bandages  away,  and  control  the  bleeding  at  the  vessel's 
mouth.  The  flow  of  blood  arrested  temporarily,  the  surgeon  can 
consider  what  further  assistance  or  instruments  he  shall  require. 
Sometimes  the  exposure  of  the  wound  to  the  air,  with  the  irrita- 
tion and  pressure  of  the  finger,  will  prove  suflScient  to  close  the 
artery;  or  the  pressure  may  have  to  be  continued  for  a  time. 
There  are  several  ways  of  applying  pressure;  namely,  by  the 
hand,  the  compress,  the  roller,  the  tourniquet. 

There  are  several  kinds  of  compress,  which  may  be  applied  in 
various  ways.  Very  often  it  is  composed  of  a  roll  of  cotton,  or 
several  layers  of  cotton.  The  compress  may  be  put  directly  upon 
the  bleeding  part,  or  it  may  be  indirectly  applied.  The  compress 
properly  adjusted,  the  pressure  may  be  made  by  a  bandage  passed 
around  the  limb  or  body  with  suificicnt  tightness;  or  adhesive 
straps  may  be  employed  instead.  When  direct  pressure  is  contin- 
ued for  a  time,  it  is  in  reality  intended  to  take  the  place  of  the 
external  clot  of  blood,  which  would  form  at  the  mouth  did  not  the 
current  of  blood  constantly  force  it  away;  the  pressure  should 
therefore  be  continued  until  the  inner  clot  of  fibrin  can  have 
formed.  And  it  will  be  understood  that  the  pressure  requisite  will 
be  just  so  much  as  may  be  necessary  to  overcome  the  force  with 
which  the  blood  comes  to  the  part. 

There  is  a  danger,  into  which  I  have  seen  many  surgeons  fall, 


nip 


TREATMENT. 


203 


of  having  the  pressure  too  great,  and  of  continning  it  too  long  a 
t.me.  It  .8  an  .noised  wound;  and  although  the  desiraMtyVf 
Ob  a,„,ng  un,on  by  adhesion  is  important,  it\  never.hZ  ^'uite 
But  at  the  sal";  """""""  ™^  "'  "^'''-S  "'^  h-o-'age. 

*.  compress  he  a,i„«dtrtraXbT:^Lrr:r 
In  every  case,  however,  if  there  is  an  error,  let  it  be  on  th       d^ 

of  undue  care  to  arrest  the  hemorrhage.     When  the  prossur   1 

.nd,reet,  the  object  aimed  at  is  to  diminish  the  force  of  L  arteria 

yet  not  partteularly  mjurious.    For  further  remaVks  on  indirlt 
premre-toumiquet-vide  Aneurisms. 

tioff "  A  "sunt"""'"'''  ■'  ?'  "^^'  "'»''  °f  ""'«-  '» l-e  men- 
t  sue 'an^  T\  ""^  ?'  ''^  """"■""""S  "^  constraining  the 

Colfl^l    ^     '"'""^'  °'-."  ""'y  "='  simultaneously  in  both  ways 
Cold  watc   ,s  commonly  included  among  this  class.    A  most  valu- 

u  r.i,c' uTod   "'""■  '^  '"^  "^"'  °'  '™^- 1'  -'» «'■-=  "t 

upon    he  blood,  causmg  ,t  to  solidify  very  quickly.     It  mav  be 

rt^tfit'T"?'  '"t  1  »"»  *-"-^  in'utcrLTcLr! 
rhag. ,  and  .t  may  be  appi.ed  directly  to  a  bleeding  part  bv  a 
p.eceof  cotton  saturated  in  the  lotionf    There  are  f  vaHc'.y  of 
vegetace  astr.ngents  which  may  be  employed,  but  it  is  uleces 
v  oen^nerate  them.    I  mention  only'one  more  astringent! 
tht  Imct.  Fcrri-which  I  have  seen  arrest  bleeding  when  other 
.neans  had  fai  ed.     Styptics  may  be  used  in  conii    ion  w  tl 
pressure,  or  other  remedial  measures      The  nuffl,.,ll  ! 
omes^rcmedy,  and  a  very  useful  one,  I!    ^bf m^liol Tw 

0    vl  e,  tl  r-1  '°  ™°«'""'^-'  ''  """"''"S  '"itahlc  materia 
upon  which  the  flunl  may  rest  and  the  fibrin  solidify 

use  to  arreln  "'°''","  P'"™,™™?  *=  -g""''  "bich  the  profession 
°  u Hr,  r  ''™:'*«':-  I*  '^  "»'  »«  ™»™only  resorted  to  now 
am  the  days  of  barbannra,  yet  even  now  it  is  used  by  some  and 
».th  success;  but  it  should  not  be  employed  when  a  less  nt'i,!ft,l 
-d  starthng  remedy  can  be  used.     A  'heated  iron  ,  p,d  ed  t'    tS 

«  „g  part  forms  a  charred  covering;  the  artcrhd'tiss  „   J 
"'«t  around,  ,s  destroyed,  and  a.  the  .an,„  time  dried  up ;  thereby 


11    I 


204 


PRINCIPLES    OF    SURGERY. 


the  vessel  is  temporarily  closed ;  there  is  formed  a  substitute  for 
the  external  clot,  and  thereafter  the  internal  clot  may  be  able  to 
form.  But,  inasmuch  as  the  eschar  will  have  to  separate  from  the 
living  tissue  by  a  process  of  suppuration,  there  will  always  be  a 
doubt  whether  the  fibrinous  plug  will  become  affected,  and  degene- 
rate so  as  to  open  again  the  mouth  of  the  vessel ;  but,  in  many 
cases,  the  fibrin  will  be  suflSciently  organized  to  resist  the  influence 
of  suppuration.  The  cautery  should  be  heated  to  white  heat,  so 
that  it  will  completely  dry  up  the  tissue ,  and,  consequently,  there 
will  be  less  of  suppuration  as  the  eschar  becomes  detached,  and 
the  danger  of  secondary  hemorrhage  will  not  be  so  great. 

Nitrate  of  silver,  as  a  potential  cautery,  is  of  great  utility.  It 
seems  to  act  in  two  ways:  first,  by  drying  up  the  tissue,  and 
thereby  closing  the  vessel ;  secondly,  by  inducing  coagulation.  It 
may  be  used  to  advantage  in  small  wounds,  where  union  by  adhe- 
sion cannot  be  expected. 

The  ligature  is  an  agent  for  the  arrest  of  hemorrhage,  which 
demands  a  somewhat  extended  notice.  It  is  as  useful  as  it  is  old. 
Different  kinds  of  ligature  have,  from  time  to  time,  been  employed 
by  the  profession.  The  changes  which  have  taken  place  have  re- 
lated to  the  material  of  which  it  was  made,  and  to  its  shape  and 
To  give  a  history  of  the  ligature,  although  interesting, 


size. 


would  not  be  of  suflicient  practical  use  to  warrant  its  introduction 
here.  The  round  ligature,  made  of  well-twisted  silk,  somewhat 
waxed,  is  the  one  now  very  generally  u^ed.  The  celebrated  Hun- 
ter used  a  flat  and  somewhat  broad  ligature.  The  principles  upon 
which  this  practice  was  based  were  erroneous,  namely,  that  if  the 
surfaces  of  the  inner  coat  were  brought  together  and  there  re- 
tained, union  by  adhesion  would  result,  and  the  danger  of  suppu- 
ration within  the  vessel  would  be  averted, — such  as  attends  the 
division  of  an  artery,  and  the  subsequent  sequestration  of  the 
ligature.  He  particularly  aimed  to  avoid  a  division  of  the  coats, 
and  employed  a  ligature  broad  and  flat,  that  the  surfaces  might  he 
pressed  together  without  dividing  the  tissue.  But,  unfortunately 
for  this  theory,  it  is  impossible  to  apply  a  broad  ligature  without 
extensive  detachment  of  the  artery  from  its  sheath,  which  would 
necessarily  give  rise  to  considerable  irritation.  And,  more  than 
that,  the  arterial  tissue  would  bo  deprived  of  its  nutritious  supply 
by  this  separation  of  the  sheath.     Irritation,  inflammation,  and 


ift 


TEBATMENT. 


205 


rappumtion    wm  necessarily  follow  outside  the  artery,  and  the 
process  of  adhesion  within  be  thereby  thwarted. 
This  practice  was  pursued  by  Hunter  in  connection  with  aneur- 

rardialsire         '      ''  *"  "^''"  ""  ™°''  '°""  *'""""=«  »"  «•"« 
The  theory  now  held,  and  which  may  be  considered  a  true  one, 
as  ,    has  stood  the  test  of  many,  many  years,  is  that  a  ligatur 
Je  Whed  w,th  as  little  irritation  to  the  tissue  as  is  possi! 
ble;  and  that  every  care  should  be  taken  to  preserve  the  nutritious 
vessel    Another  essential  point  in  the  theory  is,  that  the  interna 
and  »,ddle  coats  should  be  divided.     To  secure  the  above  indica 
«ons  the  round  l.gatnre  is  employed.     The  surgeon  divides  no 
more  of  the  tjssue  with  the  knife,  than  is  necessary  to  reach  the 
artery;  and  then,  with  the  greatest  care  and  gentleness,  pas  es 
the  tenaculum  around  U.     Finally,  the  ligature  is  tied  aromd  the 
vessel  w,th  sufficient  firmness  to  divide  the  coats  within,  which  he 
surgeon  can  know  by  feeling  a  yielding  sensation,  while  the  exter- 
nal  coat  remams  unbroken.     The  coats  within,  immediately  upon 
being  divjded,  contract  and  retract,  so  that  they  are  drawn  some 
istance  from    he  seat  of  the  ligature.     Heroin  seems  to  consis 
U,    safety  of  the  operation.    That  portion  of  the  eternal  coa 
which  ,s  embraced  by  the  ligature,  is  doomed  to  destruction;  and 
the  work  of  Its  sequestration  will  be  attended  by  ulcerative  in- 

m tation,  the  inner  coats  having  retracted  from  the  place  where  • 
ha.  irritation  exists,  the  formation  of  a  clot  of  fibrin  will  duW 
Ukc  place,  which  will  not  be  exposed  by  the  subsequent  ulceration 
and  separation  of  the  ligature,  unless  it  should  be  considerable 
In  favorable  cases  the  pus  formed  may  be  measured  by  drops. 
The  advantages  of  the  round  ligature,  it  will  be  seen,  are  twofold- 
.1  can  be  more  easily  applied,  and  by  being  tightly  applied  h 
dmdes  the  internal  coats  so  that  they  retract  ffom  Ac'plce 
irritation,  where  a  permanent  plug  of  fibrin  is  allowed  to  form. 
The  ligature  may  be  used  to  the  open  vessel  in  the  wound,  or 

T  e  operation  for  cutting  down  upon  an  artery  for  it,  ligatb,^ 

toTvi„°  1  '"  '"  "■'  '™""""'  °f  »«"""»»•     With  rC  .1 

to  tying  a  vessel  in  a  wound  the  surgeon  should  remember,  in  using 

the  forceps  or  tenaculum,  to  make  as  little  tra.'ti.m  a-  -....;". 


lii 


}. 


tl' 


i   ! 


t|.1i 


I: 


1 1 

It 


206 


PRINCIPLES    OF    SURGERY. 


The  artery  should  be  only  raised  sufficiently  to  allow  the  application 
of  the  ligature.  And  when  tying  the  knot,  care  must  be  taken  to 
so  hold  the  ligature  that  the  vessel  will  not  be  disturbed  in  its  bed. 
This  is  essential,  that  the  sheath  may  not  be  separated.  It  is 
always  desirable  that  only  the  arterial  tissue  shall  be  inclosed  in 
the  ligature ;  but  sometimes  it  will  be  so  contracted,  that  some  of 
the  tissue  around  will  necessarily  be  included  in  the  mass.  The 
larger  the  mass  the  greater  will  necessarily  be  the  ulceration,  de- 
struction, and  obstacle  to  union  by  adhesion.  After  tying  the 
knot,  one  end  will  be  cut  oiF,  while  the  other  will  be  allowed  to 
remain  hanging  from  a  corner  of  the  wound,  so  that  it  may  be  re- 
moved from  the  wound  when  it  has  separated  by  ulceration  from 
the  artery.  The  requisite  time,  for  this  work  of  nature,  will  de- 
pend upon  the  size  of  the  artery  and  some  other  circumstances. 
The  time  given  by  most  authorities  varies  from  ten  to  twenty  days, 
with  the  average  being  fifteen  days. 

The  existence  of  this  ligature  in  a  wound  may  be  the  only  bar 
to  a  speedy  union  by  adhesion,  and  the  surgeon  may  be  tempted 
to  try  at  an  early  date  to  extract  it.  Any  such  procedure  is 
attended  with  great  danger  of  secondary  hemorrhage.  It  is  neces- 
sary to  wait  until  the  ligature  is  in  all  probability  sequestrated. 
In  removing  it  no  force  should  be  used  whatever.  The  surgeon 
should  make  the  very  least  degree  of  traction,  and  should  it  at 
once  yield,  it  is  well ;  but  if  there  be  the  slightest  holding,  he 
'  must  at  once  desist.  The  danger  consists  in  this :  if  the  artery  be 
disturbed  before  the  inner  plug  is  firmly  established,  it  may  be 
dislodged,  and  thereby  the  vessel  be  opened.  From  time  to  time 
the  trial  may  be  repeated  until  it  is  found  to  be  separated.  I  have 
in  mind  a  case  where,  after  amputation  at  the  shoulder-joint,  an 
injudicious  eflfort  was  made  to  extract  the  main  ligature.  In  a  few 
hours  after,  alarming  hemorrhage  came  on ;  the  result  was,  that 
the  wound  had  to  be  opened  and  the  artery  tied  again. 

Occasionally  the  ligature,  although  quite  detached,  will  be  held 
somewhat  firmly  by  the  granulations.  This  can  only  be  inferred, 
after  a  long  time  has  elapsed. 

Torsion  consists  in  seizing  the  divided  artery,  and  drawing  it 
slightly  from  the  sheath,  and  then  so  twist  it  as  to  crush  and  lace- 
rate the  coats.  By  referring  to  lacerated  and  contused  wounds,  it 
will  be  seen  that  in  them  the  hemorrhage  is  not  so  great  as  in  the 


•  »  r 


TREATMENT. 


207 


incised.     The  irritation  of  laceration  causes  a  greater  contraction 

Somefmes  the  seizing  „f  the  vessel  with  the  forceps,  and  hold- 
ing .t  for  a  moment,  will  prove  snffieient  to  arrest  blading 

.l™^„.«re._Another  agent  yet  to  be  noticed,  is  a  form  of 
teect.pressnre.    It  .s  not  as  yet  in  general  use ;  bm  is,  no  doubt 
of  great  value     Dr.  Simpson,  of  Edinburgh,  has  introduced  it  and 
commends  ..  highly  to  the  profession.     Certainly  the  principles 
.re  most  sound  upon  which  the  practice  is  based.     I„  the  ampu  a- 
..on  of  a  large  l.mb  the  ligature  which  is  applied  to  the  prrncipa, 
artery  w,l  very  materially  interfere  with  healing  by  primary  adhe 
s.on  and  the  process  of  sequestration  of  the  ligature  will  !oL  long 
fme  delay  a  perfect  recovery.    In  view  of  these  facts  it  can  b! 
readdy  understood  that  if  the  ligature,  the  foreign  body,  could  be 
reujeved  th,s  delay  would  not  be  so  protracted.    Now  the  ligature 
s  ,ed  around  he  artery  to  an-est  the  blood  until  the  plug  of  fibrin 
as  formed  w,th,n;   after  this  has  been  accomplishedf  it  is  Z 
longer  required;  but  there  it  must  remain  until  the  pro  ess  of 
»eparat,on  by  ulcerative  inflammation  is  accomplished.     This 
however,  endangers  the  integrity  of  the  inner  clot.     Could,  thej^ 
ore  the  hgature  be  untied,  or  divided  so  that  it  might  be  ex. 
traded,  the  process  of  recovery  in  the  stump  would  be  hastened 
and  secondary  hemorrhage  averted.    Dr.  Simpson  proposes  to 
subsftute  for  the  ligature,  a  substance  that  m!y  at  a'nTtil    b 
U  en  away ;  and  which,  while  in  the  wound,  is  even  less  Lra  ing 
than  the  l.gature.     A  pm,  of  suitable  size,  is  passed  from  the  in 
tegument  of  the  flap  in  which  the  artery  is  sftuated,  and  i?  hen 
made  to  appear  on  the  cut  surface  of  the  flap  jus    beside  the 
artery;  ,t  ,s  now  made  to  bridge  over  the  mouth  of  the  vessel  and 

of    he  skin.     By  this  means  pressure  is  made  upon  the  vessel 
wh.l„  the  vtality  of  the  arterial  coats  is  not  at  aU  ie  pard  zed' 
When  the  artery  has  become  permanently  sealed  by  6^1^ wi  h  n 
he  pm  can  be  extracted,  and  nothing  remains  to  interL   with 
the  quick  and  permanent  work  of  repair  by  adhesion. 

Not  having  had  an  opportunity  of  testing  the  practicability  of 

Ins  procedure,  I  can  only  say  that  the  principles  are  sucli  as 

commend  themselves  to  the  reflecting  surgeon.    Indee,!.  I  can 


j 


■( 


I  hi 


208 


PRINCIPLES    OP    SURGERY. 


hardly  think  that  Professor  Simpson  (whose  kindness  to  me,  while 
in  Edinburgh,  I  remember  with  gratitude),  who  enjoys  a  world- 
wide reputation,  could  be  led  astray  by  anything  doubtful. 

I  have  now  noticed  the  most  important  remedies  for  local  use  in 
the  treatment  of  hemorrhage,  every  one  of  which  is  used  with 
strict  attention  to  the  way  in  which  nature  travels  to  do  the  same 
thing.  They  are  all  designed  to  aid  in  the  process  of  natural 
hcemoatatiea. 

Constitutional  Means  to  Arrest  Hemorrhage. — It  is  often  neces- 
sary to  resort  to  constitutional  measures  to  arrest  bleeding  from 
arteries ;  perhaps  in  connection  with  local  treatment ;  perhaps 
when  it  is  impossible  to  successfully  employ  local  remedies.  Here 
again  let  us  study  the  operations  of  nature,  that  we  may  learn  the 
true  principles  of  constitutional  treatment.  The  phenomena  of 
fainting  from  loss  of  blood  supplies  us  the  necessary  lesson. 

Among  other  symptoms  of  fainting,  is  a  very  feeble  pulse,  indi- 
cating a  diminished  action  of  the  heart,  and  a  tardy  flow  of  blood 
through  the  arterial  system.  Therefore  it  often  follows,  when  the 
vessel  is  not  large  especially,  that  as  soon  as  fainting  occurs  the 
bleeding  ceases,  and  at  all  times  the  flow  is  diminished  in  force. 
Now,  it  not  unfrequently  happens  that  during  the  period  of  syn- 
cope, while  the  blood  is  flowing  slowly  and  with  little  force,  a  clot 
will  have  opportunity  to  form  in  the  orifice  of  the  vessel,  and  with 
sufficient  firmness  to  resist  the  volume  of  blood  when  it  again 
comes  in  full  force.  While  the  blood  flowed  with  natural  force, 
this  was  impossible ;  but  when  it  came  with  lessened  speed,  the 
tendency  to  form  a  coagulum  prevailed,  and  thus  the  hemorrhage 
became  arrested.  From  this  fact  it  will  be  learned,  that  when  a 
person  faints  from  loss  of  blood,  he  should  not  be  hurriedly  re- 
stored to  animation,  but  rather  he  ought  to  be  allowed  to  remain 
in  a  state  so  favorable  to  natural  haemostatics,  unless  there  should 
be  danger  of  sinking.  And  when  the  patient  does  begin  to  re- 
cover, great  care  ought  to  be  taken  to  have  a  gradual  return  to 
power  of  the  heart ;  inasmuch  as  a  sudden  action  of  that  organ 
may — indeed,  is  likely  to — dislodge  the  clot  which  has  formed. 
Stimulants  ought  not,  therefore,  to  be  given,  unless  reaction  is 
doubtful. 

From  the  above  facts,  we  moreover  learn  that  diminished  action 
on  the  part  of  the  heart,  and  the  consequent  tardier  flow  of  blood, 


TREATMENT. 


209 


is  favorable  to  the  arrest  of  bleeding     -NTa,,  • 

involving  „teHes  whio.  ^ZtlZX^'T.  lT„t: 

chanical-of  body  and  mmd-must  not  be  forgotten.    An  assu 
ranee  to  the  patient,  when  such  can  be  »ivm  t^  .  u-  • 

aUrming.  will  have  a  tranquniilg  X";  ^.^ '"%"  "I 
the^by  upon  the  heart;  and\erfeet'ret e „f  hfd;;:tiat 
of  the  part  where  the  wound  e.i,ts,  will  materially  oondu  e  t^the 
ormafon  of  the  clot.  For  agents  to  eontrol  the  aetion  of  he 
heart,  and  to  eeonre  repoee,  there  partieularly  are  antimonT 

Seccnd<,r^  mmorrhage.-VfbiU  speaking  of  arterial  hemor 
r  age,  allna.on  has  been  n,ade  to  the  faet  that,  after  a  time  tW 
b  eedmg  may  reeur-there  may  be  .eoondar^  hemorrhre  the 
fibnnoue  clot  wuhin  the  vessel  having  been  disturbed.       ^' 

..T;:Zl^'"'^'^  ""'""-^'-^^y  "^  «"^ed  into  Ucal 

.  f"""'  f7»«— Are:    1.  Inflammatory  aetion,  by  which  the 
.nernal  clot,  mstead  of  becoming  organized,  is  made  t"  detene 
rate,  thus  openmg  the  bleeding  channel  afresh.     2.  Uleerft  on 
erhaps  ,n  consequence  of  injury  to  the  arterial  tissue,  at  the  time 
he  wound  was  received.     8.  Inconsiderate  meddlii^g  with  the 
ligature,  before  sequestration  is  completed  ^ 

Oeneral,  or  Oomliiutimal  Came,.-\re  certain  diseases  of  th. 
Wood,  oharacterked  by  unnatural  fin.dlf,  „f  ;      ,.,'"',  °'  '"« 
Tu^ci.  ■    ■   ■         ,  y  ""'""nrai  ouidity  of  its  so  id  constituents 
The  fibrin  is  incapable  of  permanent  coagulation-  it  exTsts  for  ^ 

unpleasant  a  complication.     When  the  bleeding  aetuafly  occurs 
same  rules  w,Il  be  followed  as  .re  observed  in  prima^  hem„r: 

^J;  o:r  :rdii:sir '- — -  -^  ^-  -  - 

.he^r"' Tlfrr-^'"  T'  '^'"^  "-^  <Ji"inguished  from 
^Zm7L  ,?^''t'"°°'^; '»''»'<•  »f  """^e  in  waves  and  with  an 
mpetu,  from  the  heart,  flows  in  a  more  steady  stream,  from  some 

14 


1:1.   . 


210 


PBINCIPLES    OF    SURGERY. 


distal  part,  to  the  heart ;  and  as  it  pours  from  the  wound,  it  pre- 
sents a  much  darker  hue  than  the  arterial.     The  coats  of  veins 
possess  the  power  to  contract,  to  a  limited  extent ;  but  by  no  means 
so  great  as  the  arterial  do.     They  are  comparatively  lax ;  and 
when  the  vein  is  empty,  it  is  quite  collapsed.     The  venous  system 
is  such,  that  if  one  channel  is  occluded,  or  otherwise  becomes  in- 
capable of  containing  blood,  the  fluid  may  find  other  channels  by 
which  to  pass  on  in  its  course.     And,  in  a  large  number  of  cases, 
as  soon  as  a  wounded  vein  has  emptied  itself,  the  hemorrhage 
ceases,  to  a  great  extent,  or  altogether.     In  a  certain  number  of 
other  cases,  temporary  pressure  by  the  finger  upon  the  bleeding 
vessel  will  be   sufficient   to  change  the  current  into  collateral 
branches.     It  would  seem  that,  in  most  cases,  the  external  pres- 
sure by  which  the  vessel  is  collapsed  is  greater  than  that  of  the 
blood  which  was  flowing  through  it;  and  thus  the  blood  is  pre- 
vented from  entering  the  wounded  vein.     When  a  very  large  vein 
is  cut  into,  the  force  of  the  passing  blood  may  be  so  great  as  to 
prevent  collapse  of  the  vessel,  when  the  hemorrhage  will  continue. 
Treatment  of  Venous  Hemorrhage. — Direct  pressure  is,  by  far, 
the  most  suitable  agent.     It  is  conveniently  applied,  and  easily 
removed  after  it  has  served  its  purpose.     As  already  said,  tempo- 
rary pressure  by  the  finger  may  be  sufficient  to  overcome  the 
power  of  the  venous  currents     When  continued  pressure  is  re- 
quired, a  compress,  with  a  bandage  or  adhesive  straps,  will  be 
demanded.     It  is  decidedly  opposed  to  surgical  practice  to  apply 
a  ligature  to  a  vein,  unless  it  be  a  large  one.     The  fact  that  it  is 
generally  unnecessary,  is  a  sufficient  objection;  but  the  more 
commonly  recognized  objection  is  the  belief  that  such  procedure 
is  likely  to  cause  either  phlebitis  or  pyemia.     It  has  been  gene- 
rally believed  that  the  application  of  a  ligature  to  venous  tissue 
will  lead  to  extensive  suppurative  inflammation,  with  the  attending 
danger  of  the  pus  finding  entrance  into  the  circulating  blood.    In 
respect  to  this,  however,  perhaps  the  danger  has  been  overrated. 
At  all  events,  not  a  few  cases  have  been  recorded,  in  which  no  dis- 
astrous or  unpleasant  result  followed  the  ligation  of  a  vein.    ( Vide 
Pyemia.)    A  ligature,  however,  should  never  be  used  except  when 
pressure  fails  to  arrest  the  hemorrhage.     As  a  general  thing,  it 
will  require  to  be  tied  only  on  the  distal  side  of  the  wound.    Oc- 
casionally, a  second  one  on  the  cardiac  side  will  be  required.    The 


SECOND    INDICATION. 


211 


subsequent  treatment  does  nnf  Aur    r 

.fter  ligation  of  an  JZ      kf  """  "'"''''  '"  P"""^'J 

will  have  to  take  plaoe^"  '™'  ""•""'''  "'  sequestration 

the  orifice,  thereby  closL  fte;iat  ^.^''^  '   ^^'"°"  '"•°"""' 
of  the  intestine  would  he  floTed  "  "'^  °=  "  'o™* 

rh^'t^^tirrS '•'''■'  ''"""'™'  of  veno„3hen.or. 

on  fhe  oontL;'::;*:  "S  """^  '™'"'»^'  "^  --^^  o-^ 


CHAPTER   XXVI. 

vent  Inflammation.  '""^^"""'l  8»'ureB_Q„illed,    4th:  Pr.. 

Semoval  of  Foreian  Bodi,,     Tk.  ^    . 

treatment  of  ».«A,l-t„  ,„  W^'-  Tf-  ""'"'"''"'  '«  '*« 
P— ly,  a  piece  of  tie  ins  rentlhaTLtf  !,\  ^'^  "^^  '»' 
or  dirt  or  a  bit  of  clothing,  or  a  "lot  oVbtd      ""^  """'"'^  -"^ 

either^f  r:tr  If  ,:;ta:t  '"*  ^-^^ '-  "=  *-  - 

•ponge  in  the  wound;  eUtndll  ^'  "  "  "?""  ''"^  »^''''  '*e  a 
after  awhile  causing  I  Zr^tf  oTlTt" «'  """^  ^"^  '"'«'y 
Hen  it  begins  to  disintegrate  !„!  *''^t"'"'«=  '"'^  ""' '»'"' 
animal  substance,  which  f  n„ot  t  7  !'  °°""""'"  "  """ 
W^ble  and  inimical  .rhea  nTby  adltr^T^f"";''"*'^ 
■ng  by  primary  adhesion  is  sou^hf  for  T  >  ^^t'^^"'^^  ''  hea'- 
allowed  to  remain  between  1^5/'  ."'"'  "''*'<"'"  "■"«  ^ 
•"rface  or  in  the  boC  o/the  wot?  '"  '°  ""'""'  ^'"'"  "  "" 

ta4X«fsul°Ts!"ff':'r  T '" "™ '» -"- 

»»f'  «P°nge  mth  water  will  generally  be 


!t 


\\t.\ 


212 


PRINCIPLES    OF    8TTRGKRY 


adequate  to  remove  the  clotted  blood  and  dirt.    Larger  and  firmer 
bodies  can  be  extracted  by  the  dressing  forceps  or  the  finger. 

Foreign  bodies  having  been  completely  removed,  the  surgeon  is 
prepared  to  attend  to  the 

Third  indication  in  the  treatment  of  wounds,— to  approximate 
the  opposed  surfaces  of  the  wound  and  retain  them  immovably  in 
contact.  It  will  be  remembered  that  the  separation,  or  gaping,  is 
caused  by  the  contraction  of  muscle,  and  the  contractility  of  the 
tissue.  These  causes  of  gaping  must  be  removed,  or  controlled. 
It  is,  therefore,  of  primary  importance  to  relax  those  muscles  by 
-which  the  gaping  is  produced,  and  by  every  possible  means  beget 
a  state  of  quietude,  so  as  to  prevent  any  twitching,  or  irregular 
action  of  muscular  fibre.  The  first  things  to  be  attended  to  are 
position  and  rest.  The  agents,  besides,  to  be  used,  are  bandages, 
compresses,  adhesive  straps,  and  sutures. 

Bandages  prove  serviceable  in  two  ways :  first,  by  giving  sup- 
port, as  when  applied  around  a  limb;  and,  secondly,  by  controlling 
muscular  action.  The  benefit  to  be  derived  by  applying  a  bandage, 
from  the  extremity,  along  a  limb  to  the  wound,  cannot  be  too 
highly  esteemed.  In  large  deep  wounds  a  compress  placed  on 
either  side  of  the  wound,  and  bound  there  by  the  bandage,  assists 
very  materially  to  bring  the  deeper  surfaces  of  the  wound  together, 
as  well  as  the  superficial  portion.  The  pressure  made  by  the 
bandage  must  be  uniform  from  the  extremity,  to  prevent  passive 
congestion.  The  bandage  will  slacken  here  and  there  in  a  day  or 
two,  perhaps  in  a  few  hours,  and  will  require  to  be  readjusted. 
When  this  becomes  necessary,  I  have  been  in  the  habit  of  apply- 
ing a  second  bandage  over  the  first ;  as  to  remove  the  first  for  the 
purpose  of  tightening  it  would  expose  the  wound  too  much  to  dis- 
placement. 

Adhesive  straps  are  more  particularly  useful  in  superficial 
wounds,  as  they  cannot  draw  together  the  surfaces  at  the  bottom 
of  a  deep  one ;  and  when  employed  for  deep  wounds  it  can  only 
be  for  the  superficial  part.  They  should  not  therefore  in  such 
cases  be  used  alone;  as  to  bring  together  the  lips  of  a  wound, 
while  at  the  bottom  the  surfaces  remain  apart,  is  not  only  useless 
practice,  but  an  actual  evil.  The  space  at  the  bottom  of  the  wound 
will  become  filled  with  liquor  sanguinis,  the  fibrin  of  which  will 
soon  degenerate  into  pus,  and  thus  an  abscess  will  be  formed. 


THIKD    INDICATION. 


213 


»n,on  of  tho  I.p8  „.y  have  actu.ll,  takes  place.  AdhLe  ZZ 
may  do  more  than  aet  upon  the  lips  of  a  wound  if  theXp"  'ed 
fghtly  and  entirely  around  the  tab  wounded,  so^  to'make 
pressure  at  the  deeper  parts. 

Before  proceeding  to  apply  straps,  the  integument  around  ou^ht 
to  be  made  perfect  y  dry,  else  they  will  not  adhere  firmly  They 
ought  to  be  cut  m  long  strips,  which  will  insure  a  greater  probZ 
bihty  of  their  adhering,  and,  as  well,  that  rest  of  mfscTe  so  nece" 
Bary  for  immediate  union.  I  have  verv  often  «PPn  „T  • 
cut  so  short  tlio*  +1,  1 J  ^  ®^®"  adhesive  straps 

rata  ^  '"       not  possibly  secure  the  above  deside- 

to  h^al"^'  fr^^  "'?'  *°°  ^^^^'  *^«^«  <>"gh*  -t  the  same  time 

wound  ''ZT''"  *''"'  *^  ^"^"  *^^  ««^"^  *°  --Pe  from": 
wound.  I  ,s  also  important  to  have  the  straps  fit  snLly  to  the 
skm  in  their  whole  extent :  to  secure  tl„'«  ,-f  -J  ^^ 

fere  with  .hf  union  W  adti^  Thf ';!"' r*^ 'f""'^  "'''■ 
found  far  n.ore  serviceVe  irVel'    e.  Xe  ^T  nt: 

woun^«  «?     .u  ^''''*'®  '"  amputations,  and  very  We 

wounds,  as  m  these  cases  it  mav  fail  nn«fl;Ki.r  *^  .        ^ 

sarv  renosp  of  th^  *•         \      .        possibly  to  secure  the  neces- 

^i^z^  t^oTi  at:- :s:"^  -^ "»"- "  ^^  ^»- 


■  -( 


214 


PRINCIPLES    OP    SURGERY. 


Sutures.— There  are  several  kinds  of  sutures.  There  are  divi- 
sions  based  on  the  material  employed  and  on  the  manner  in  which 
they  are  employed.  First,  as  to  the  method  of  using  sutures. 
There  are  the  Interrupted  suture,  the  Ur interrupted,  the  Twisted, 
the  Quill.  Speaking  generally,  the  legitimate  use  of  the  suture  is 
simply  to  prevent  a  sliding  motion  of  the  sides  of  the  wound,  and 
not  to  forcibly  draw  them  together,  and  thus  retain  them.  Other 
agents  should  be  employed,  which  have  already  been  given,  to 
bring  and  hold  the  surfaces  together.  The  surfaces  of  the  wound 
being  in  contact,  or  nearly  so,  then  a  stitch  introduced  will  assist 
to  fix  the  parts,  so  that  union  can  the  more  readily  take  place. 
But  the  gaping  wound  should  never  be  forcibly  closed  by  the  su- 
ture alone,  as  it,  by  dragging  upon  the  structures,  will  produce 
irritation  and  twitching  of  the  muscles,  while  at  the  same  time 
they  will  prove  inadequate  to  accomplish  what  is  aimed  at. 

The  number  of  sutures,  and  the  depth  to  which  they  require  to 
be  placed,  will  depend  upon  the  size  of  the  wound.  Speaking  more 
particularly  of  the  interrupted  suture,  it  ought  not  to  be  intro- 
duced until  the  bleeding  has  entirely  ceased,  at  least  it  should  not 
be  tied.  Care  must  be  taken  to  have  the  surfaces  strictly  in  ap- 
position ;  to  secure  this  the  suture  will  be,  at  first,  introduced  in 
the  middle  of  the  wound,  and  then  on  either  side,  as  many  as  may 
be  necessary ;  but  all  should  be  introduced  before  one  is  tied. 
The  central  one  should  be  first  fastened.  The  knot  must  not  be 
over  the  wound,  but  to  one  or  other  side.  This  is  to  avoid  irrita- 
tion at  the  place  where  the  bond  of  union  is  undergoing  develop- 
ment. After  the  suture  is  tied  both  ends  will  be  closely  cut.  The 
surgeon  must  not  forget  that  it  is  only  necessary  to  bring  the  sides 
together.  I  have  very  often  seen  the  lips  of  the  wound  quite 
puckered  from  the  suture  being  too  tightly  drawn. 

It  is  commonly  recommended  to  allow  the  si-  -^  ■■»  remain  for 
thirty  or  fifty  hours,  or  until  there  appears  a  I'iU  '  •  33  where 
the  suture  passes  through  the  intej^ument.  ^he  presence  of  the 
foreign  substance  is  offensive,  «iid  ^i1)  iT^terfert  with  the  bueccsf^^u! 
issue  of  healing  by  adhesion  if  allowed  to  remain  for  too  long  a 
time.  Therefore,  so  soor  as  the  wound  is  firmly  closed,  the  suture 
o;tg>  :.  to  be  taken  awaj  I  think  it  is  more  frequently  permitted 
to  xtuiajj)  too  long  than  too  short  a  time.  When  they  are  ex- 
tractc-'l,  they  ought  to  be  substituted  by  the  adhesive  straps.    The 


THIRD    INBIOAIlOlf. 


216 


necessuy  of  an  early  removal  of  the  ,„t„re  must  not  be  over- 
oked,  a,  .t  may  lead  to  the  formation  of  pus  at  the  botlmo" 

The  iy.,ted  Suture.-Th,  remarks  made  thus  far  have  been 
more  part,cu larly  direeted  to  the  interrupted  suture,  the  proper 
u^e  of  wh,oh  ,s  to  retain  at  rest  the  surfaces  brought  togethe"  by 
other  means.    But  in  eertain  kinds  of  wounds,  the  suLon  wiu 
find  .t  necessary  to  use  the  suture  to  bring  .og;thor  theTurface 
n  ,„ch  cases  to  obviate  the  evil  „hieh  would  result  from  the  o" 
d,n.vy  .uture  dragging  on  the  tissue  through  which  it  is  passed  J 
pu,  prepared  for  the  purpose,  is  introduced  at  some  distance  fl 
...  I.p  of  the  wound,  and  made  to  traverse  the  deeper  part  of  the 
wound  to  an  equal  distance  from  the  lip  of  the  opposite  side 
The  second  step  is  to  place  a  piece  of  waxed  silk  around  one    „d 
f  .he  p,n  and  then  wind  it  around  the  two  ends  in  the  form  of  . 
figure  e,ght.    An  assistant  will  hold  the  wound  together  while  this 

wil  ri    T'Tl,  "t"  """  "P»'^''»"  '»  «-Pleted,  tW  wound 

w,l  be  firmly  closed.     The  advantage  of  this,  the  twisted  suture 

s  sufficently  flam.     The  pin  fixes  the  sides  of  the  wound  and 

he  s,lk  crossed  and  bound  around  the  ends,  exerts  pressure  „1 

fc  surface  of  the  part,  by  which  the  wound  is  retained  :Z 

The  twisted  suture  is  principally  used  when  there  is  »  loss  of 

n  egument,  or  where  there  is  much  gaping.    It  is  most  frequently 

re  orted  to  .n  wounds  of  the  face,  when  it  is  desirable  to  prevent 

.he^ex,stence  of  a  scar.     It  forms  a  part  of  the  treatm'enr^J 

The  Quitted  Suture.-The  advantage  of  the  quilled  suture  is 

m  most  respects,  the  same  as  that  of  L  twisted     It  is  gene' al w 

™ed  ,„  wounds  and  operations  about  the  perineum,  where  th^ 

^>'.sted  suture  could  not  be  employed.    It  consists  of  ^  many  n 

errupted  sutures  as  may  be  necessary,  and  two  substancr  alut 

s,ze  of  a  qu,Il,  one  placed  on  either  side  of  the  wound.     The 

eTtheTf-  ""  'r?'"""''  °"«  ^■"'  °f  ^""l'  »  l»»Pea  around 
1     ,!.    ^f '■/»'»  ">«  "'her  ends  are  tied  sufflciently  tight 
ar  and  the  body  of  the  opposite  side.    By  means  of  these  bodfes 
x»  mg  the  length  of  the  wound,  diffused  pressure  is  mtde 
Id  ^^™™'  "'  ""■"  "•'«•  "-y  ^'^'=1'  «'«  ^"-"i  fe  kep 


*■■<: 


H 

n 

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IB 

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in 

r    .f 

il 

,      1 

1  il 

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il 

1 

:        !* ' 

III 

,,       1 

HI 

'  ''      ^ 

m^m  1 

clll 

SI 

Jfill 

H'  M 

HIH 

M'l  il 

HI 

1  '{ 

V^^E^R*  ^^^1 

'     '(■■ 

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i.ill 

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f 


<      i\ 


216 


PRINCIPLES    OF    SUEGBRY. 


Diviiion  of  Sutures,  based  on  the  material. — There  are  two 
kinds  of  sutures,  as  to  the  material  composing  it.  One  is  of  metal 
— iron  or  silver ;  the  other  is  of  silk  or  hemp.  The  silk  suture  is 
of  a  more  ancient  use  than  the  metallic ;  hut  within  the  last  fifteen 
years,  the  latter  has,  to  a  great  extent,  superseded  its  use.  The 
metallic  suture  is  more  cleanly,  and  less  irritating,  than  the  silk ; 
but  its  removal  is  attended  with  some  diflSculty,  and  is  likely  to 
cause  irritation,  and  disturb  the  process  of  healing.  I  cannot  say 
that  I  have  observed  that  extra  advantage  from  its  use  for  which 
it  is  so  strongly  recommended. 

Fourth  indication  in  the  treatment  of  wounds,  is  to  prevent,  or 
control,  or  subdue,  inflammation.  It  should  be  well  understood 
that  no  extraordinary  flow  of  blood  is  necessary  to  secure  the 
healing  by  adhesion.  Healing  is  a  physiological  action,  for  which 
no  excess  of  blood  is  requisite ;  rather  the  congestion  will  subvert 
the  process  of  healing,  and  lead  to  inflammatory  action. 

The  local  applications  consist  in  the  use  of  cold  water  dressing, 
in  connection  with  which,  the  same  attention  and  the  same  precau- 
tions must  be  observed  as  are  referred  to  in  the  treatment  of  in- 
flammation. It  is  a  fortunate  thing  that  cold  applications  tend 
both  to  the  arrest  of  hemorrhage  and  the  prevention  of  inflam- 
mation. 

Such  constitutional  measures  will  be  adopted  as  are  recom- 
mended in  connection  with  the  subject  of  inflammation. 

The  surgeon,  in  treating  incised  wounds,  seeks  to  obtain  union 
by  primary  adhesion ;  but  it  will  occasionally  happen  that,  either 
from  constitutional  defect  or  the  absence  of  some  essential  local 
condition,  adhesion  does  not  follow  his  treatment.  Whatever  may 
be  the  obstacle  to  union,  as  soon  as  the  fibrin,  which  should  have 
served  as  a  bond  of  union,  has  degenerated  into  pus,  free  egress 
for  it  must  be  made  by  the  removal  of  the  bandages  and  sutures. 
And  if  there  be  pain,  indicating  the  formation  of  pus  at  the  bot- 
tom of  the  wound,  soothing  applications,  as  a  poultice,  must  at 
or  ,e  supersede  the  former  treatment.  Healing,  thereafter,  will 
have  to  take  place  by  granulation  or  secondary  adhesion. 


LACERATED    WOUNDS. 


217 


re  recom- 


CHAPTERXXVII. 

Lacerated  Wounds :  Characteristics-Treatment.     Contused  Wounds  •  Treat 
ment.     Punctured  Wounds :  Characteristics-Treatment 

By  a  Wa«.rf  wound  is  understood  a  solution  of  continuity 
attended  with  a  stretching  of  the  tissue  around  the  wound  from 
which  Its  vitality  is  impaired,  or  perhaps  destroyed.  The  fo;ce  by 
which  the  division  of  tissue  is  effected  is  generally  indirect,  in  the 
same  manner  as  the  force  applied  by  the  hands  is  indirect  which 
tears  a  piece  of  linen.  The  whole  of  the  tissue,  between  the  two 
points  at  which  the  power  had  been  applied,  was  necessarily  placed 
upon  the  stretch,  and  it  was  a  chance  circumstance  which'^caused 
division  to  take  p  ace  in  one  place  sooner  than  in  another;  hence 
that^injured  condition  of  tissue  characteristic  of  the  lacerated 

Characteristics.-.^},,  wound  does  not  present  that  even  surface 
which  IS  seen  in  the  incised;  rather  it  is  irregular,  with  ragged 
margins-uneven  edges-perhaps  hanging  in  shreds,  or  flaps 
The^aen,  instead  of  being  of  a  smarting  nature,  is  more  decidedly 
acute,  or  perhaps,  on  the  contrary,  altogether  absent.  In  the 
former  case,  the  nerves  have  been  much  irritated;  in  the  latter, 
they  have  been  benumbed  or  paralyzed. 

Hemorrhaged  comparatively  slight,  as  the  laceration  promotes 
the  closure  of  divided  arteries,  and  the  coagulation  of  blood     The 
coats  more  sneedily  and  effectually  contract,  while  the  rough  and 
glazed  prominences  on  the  surface  of  the  wound  offer  so  many 
po.nts  around  which  coagulation  may  commence.     Consequently 
bVZT'   "^  ^-go  artery  may  be  divided,  and  yet  the  bleeding 
bo  speedily  arrested  by  the  unaided  powers  of  nature.     Cases 
ndeed,  are  recorded,  where  a  large  limb  was  torn  off  and  n 
hemorrhage  ensued. 

The  gaping  is  by  no  means  so  great  as  in  the  incised.     The 

Z.T':'t  '"T  --P-itates  them  for  contraction 
that,  although  the  wound  is  of  equal  size  with  the  incited,  the 


-r  f 


f    I 


218 


PRINCIPLBS    OF    SURGERY. 


■ii 


gaping  is  much  less.  The  absence  of  these  two  symptoms — bleed- 
ing and  gaping — which  are  so  well-marked  in  the  incised,  not  un- 
frequently  leads  to  the  belief,  on  the  part  of  the  patient,  that  the 
wound  is  comparatively  of  little  importance.  In  like  manner,  the 
inexperienced  surgeon  may  be  misled. 

The  lacerated  wound  is  more  serious,  because  the  injured  tissue 
around  the  wound  has  to  be  restored  in  vitality  before  healing  can 
commence. 

A  lacerated  wounJ  may  terminate  in  immediate  union,  if  the 
tissue  have  been  but  slightly  injured ;  on  the  contrary,  there  may 
follow  inflammation,  or  ulceration,  or  sloughing,  or  even  gangrene. 
Much  will  depend  upon  the  extent  to  which  the  vitality  of  the  tis- 
sue is  impaired ;  also  upon  the  recuperative  powers  of  the  system 
or  the  part.  As  a  general  thing,  some  portion  of  the  tissue  bor- 
dering the  wound,  which  has  been  stretched,  will  perish,  while 
other  portions  will  gradually  be  restored  to  normal  vitality.  Na- 
ture, whose  leadings  the  surgeon  must  here  still  follow,  will  take 
steps  to  ascertain  how  much  of  the  affected  structures  will  recover 
and  how  much  must  perish,  and  then  will  proceed  to  establish  the 
line  of  separation  between  the  living  and  the  dead.  This  line  will 
not  be  regular  in  its  course,  but  it  will  be  definite.  The  formation 
of  the  line  will  be  followed  by  sequestration  of  the  debris,  either 
in  the  form  of  ulceration  or  sloughing.  Simultaneously,  the  adja- 
cent tissue  will  be  restored  to  health ;  and  immediately  thereafter, 
healing  by  granulation  will  commence.  Attending  the  separation 
of  the  destroyed  tissue,  will  be  a  degree  of  inflammatory  action. 
This  is  necessary  to  the  separation.  But  care  must  be  taken  that 
the  inflammation  is  not  unnecessarily  great. 

The  surgeon  cannot  always  be  certain  as  to  the  termination  of 
a  lacerated  wound.  As  before  intimated,  the  wound  may  be  more 
serious  than  appearances  would  seem  to  indicate.  It  can  T^gver  be 
known  to  what  extent  the  tissue  has  suffered ;  perhaps,  while  a 
part  of  the  wound  is  lacerated,  another  part  is  simply  incised,  in 
which  parts,  adhesion  may  speedily  ensue.  On  the  contrary,  a 
part  may  be  bruised,  which  condition  is  quite  as  injurious  as  lace- 
ration. The  character  of  the  instrumont  by  which  the  wound  has 
been  inflicted  will  assist  in  determining  the  diagnosis  and  prog- 
nosis. A  portion  of  the  instrument  may  have  a  sharp  edge,  while 
another  portion  may  be  blunt ;  or  the  cutting  portion  may  have 


LACERATED    WOUNDS. 


219 


been  followed  by  the  handle,  which  has  forcibly  torn  the  wound 
wider,  or  perhaps  has  bruised  the  tissue  around 

Lacerated  wounds  are  not  equally  serious  in  every  part  of  the 
body.  Cases  are  recorded  in  which  very  extensive  lacerations  of 
the  scalp  united  very  quickly. 

Treatment  of  Lacerated  Wcund^.-ArrcBt  the  hemorrhage,  re- 
move  fo^gu  bod.ea,  and  treat  the  inflammation;  and  then  -the 
p.  ho  logy  .ell  understood,  and  the  physiological  action  'whl 
»■  be  d  splayed,  properly  appreoiated,_the  duty  of  the  nrgeon 
W.1I  be  s,n,ple  and  easy.  As  in  the  incised,  so  in  the  lacerllT 
the  surgeon  can  but  be  the  handmaid  of  nature 

and  proper  crcumstances  are  necessary,  that  the  doomed  pouZ 
«y    e  cast  off  and  the  living  portion  restored  to  a  state  of  health 

U\       "T       !''*'  """'  'o  «"«">•''  sequestration,  the  flo.  of 
Mood  does  not  requ„-e  to  be  great;  there  must  not  he  too  much 
If  the  crculafou  be  too  free,  inflammation  is  favored,  restoration 
.s  delayed    and  destruction  of  tissue  increased.     I^flammatorv 
ac  ,on  w,ll    however,  undoubtedly  hasten  the  separation  "fZ 
des  royed  tissue;   but  it  will   likewise  increase  the  amount  of 
destrucon  and  the  breach  to  he  healed.     There  must  be  s„lu 
rauou;  but  the  flow  of  blood  need  not  exceed,  to  anTex  en  X 
natural  quantity.     To  secure  these  essential  circumstan  e"  tta 
.nd,ca.ed  the  surgeon  has  only  to  maintain  the  natural  temper 
.     e  of  the  part    and  the  ordinary  circulation.    Although  the 

hroTtt"       V:.""'  '""""=''  """"'^  '"  ''""^  "iff"™'  from 
that  of  he  ncsed,  the  treatment  required  is  essentially  the  same 

Cold  water  treatment  ought  to  be  adopted,  as  a  generaUhing  ;Tu; 

«.  the  tissue  ,s  wanting  in  that  vitality  which  was  present  fn  the 

.ncsed  wound  care  must  be  taken  that  the  cold  beLt  to    great 

The  only  guide-and  it  is  infallible-is  to  apply  the  water  si 

-ti.  cold  and  with  sufficient  diligence,  to  pTefe^t  cIi  ^    t   „ 

slightest  elevation  of  temperature  ;  and  no  more  than  ttat.    J„ 

cxtnsive  wounds,  it  will  be  necessary  to  administer  medicines  to 

Z;      m"  """^  "V^  '"'"^'-     "  ■'"'  •'-"  '-"".-emJed  by 
ome,  in  those  case,  where  the  pain  is  great  from  the  laceration  of 

t     n  rve,   to  apply  a  cold  poultice.     In  some  instances,  r   i„f 
found  to  accomplish  the  same  end,  and  at  the  same  time  it  will 


'  1 


■I  '•\ 


220 


PRINCIPLBS    OP    SURGERY. 


1 
1    il 


more  surely  limit  the  inflammation.  Sometimes,  however,  in  ex- 
tensive tears,  the  tissue  will  have  suffered  so  much,  or  the  system 
experienced  such  a  shock,  that  warm  applications  of  water  or 
poultice  will  be  demanded,  to  raise  the  heat  to  the  natural  stand- 
ard. As  soon,  however,  as  this  has  been  obtained,  they  must  be 
discontinued;  and  when  the  action  begins  to  be  excessive,  as  it 
will,  cold  dressing  must  be  employed  instead.  In  these  cases,  the 
feelings  of  the  patient  will  indicate,  somewhat,  the  most  suitable 
application. 

In  every  case,  the  patient's  general  comfort  ought  to  be  attended 
to.  Repose  of  body  and  mind  ought  to  be,  if  possible,  secured  to 
him.  When  necessary,  local  support  should  be  supplied  by  straps, 
bandages,  or  splints.  In  a  pure  case  of  lacerated  wound,  no  at- 
tempt should  be  made  to  bring  the  sides  of  the  wound  together  by 
sutures.  The  sides  ought  to  be  approximated  and  firmly  sustained, 
but  not  brought  actually  together ;  unless,  indeed,  a  portion  of  the 
wound  be  incised,  and  there  be  a  fair  prospect  of  adhesion  of  a 
part  presenting  itself.  Attention  to  position  is  a  matter  of  some 
importance,  so  that  passive  congestion  may  be  averted.  When 
the  line  of  demarcation  has  formed,  and  there  is  a  slough  to  be 
separated,  the  occasional  use  of  a  poultice  may  prove  beneficial. 

Contused  Wounds. — In  this  wound  there  is  bruising  or  crushing 
of  the  tissue.  It  is  caused  by  some  body  coming  against  the  tis- 
sue with  a  force  suflicient  to  cause  a  solution  of  continuity.  Also 
a  blunt  instrument  may  produce  it,  which,  although  dividing  the 
tissue,  yet  bruises  it  in  its  course.  The  difference,  then,  between 
a  pure  case  of  lacerated  wound  and  a  contused  one,  is  this :  in  the 
former,  the  tissue  has  been  stretched  until  its  vitality  has  been 
impaired ;  in  the  latter,  it  has  been  subjected  to  bruising  until  its 
integrity  has  been  affected. 

The  characteristics  are  nearly  the  same  as  those  of  the  lacerated 
wound.  The  surfaces  are  irregular,  the  margins  uneven.  The 
pain  is  not  great,  perhaps  absent,  the  nerves  being  bruised  to 
numbness.  Hemorrhage  is  not  great;  but  in  the  bruised  and 
jelly-like  tissue  around,  there  is  more  or  less  effusion  of  blood. 
The  vessels  do  not  contract  so  much  as  in  the  lacerated ;  rather 
they  are  dilated,  at  least  are  unable  to  contract.  The  result  iB, 
an  escape  of  blood  into  the  softened  tissue.  But,  although  the 
bloodvessels  do  not  contract,  the  state  of  the  tissue  favors  quiclc 


PBSCTOKED    WOOKDS. 


221 


coagulation  so  that  hemorrhage  i,  not  great  as  a  general  thin.r 
Somefmea  the  blood  will  collect  in  thf  tissue,  thf  p       ne    ff 

veslels  a7e  „fte?tt       ""  '"r"'  '■"■  '"'  "»■"'''  ■"""»"-  «f  "e 
vessels,  are  often  the  cause  of  secondary  hemorrhage.    This  unfor 

.  nate  comphcation  is  more  apt  to  follow  in  the  ptoess  o   "ker 
afon  or  sloughing,  than  in  the  lacerated  form  of  wound 

Term,n<uu,n,ana  IVea,ment.-m  termination,  of  the  contused 
wound  are  in  all  respects  the  same  as  we  have  found  in  conneo""^ 

d-ctive  of  p™,  ,  ,,,,  m!  rr^h  nlTw^:  ZZ 
must  bo  provided.  The  danger  of  sloughing'and  econdary  Cor 
h  ge  must  be  remembered  by  the  surgeon,  and  great  care  Ibsrved 
.0  limit  the  amount  of  destruction  by  ulceratiof.  The  cimiSn 
of  blood  in  the  part,  in  a  normal  manner,  is  of  the  greatestlmnorT 
.nee.  The  crushed  tissue  will  no.  at  first  endure  muct  old  .'but" 
a.  It  returns  to  life,  there  will  be  great  danger  of  ™  essTve  're« 
lion,  rendering  necessary  the  application  of  cold. 

In  the  treatment  of  both  lacerated  and  bruised  wounds,  when 
they  are  extensive,  and  it  becomes  necessary  to  resort  to  1  ill 
giatic  means  to  subdue  inflammation,  the  J^.oIZZ':^^:, 
that,  m  addition  to  the  shock  from  which  the  patient  has  sTred 
there  will  bo  a  discharge,  more  or  less  exhausting,  which  tlether 
may  overcome  the  powers  of  life.    The  immediat!  danger  mus  be 
met,  but  the  mildest  means  possible  should  be  adopted*    Instead 
therefore,  of  depletion  in  any  form,  the  strength  ough   to  be  hus 
banded,  and  perhaps  the  strongest  stimulants^resorfed  to     Th  J 
may  be  required  even  from  the  first 

acclTTft,'?''"*'"'''"'/"™  "'  "™"'l ''  ""P-"-"  bo*  on 
account  of  its  frequency  and  its  peculiar  character.    By  it  is 

commonly  understood  a  penetrating  wound  made  by  an  instfumen 

ZZoZrT'^.""  ""'  """»"^»W,  -ueh^s  a  bayonet 
the  tine  of  a  fork,  a  dagger,  or  the  point  of  a  sword.  ' 

CharacterMc  %m;,tom,._The  external  appearance  never  in 

wine  1  of  the  tissues  have  suffered,  nor  the  degree  of  daniter     The 
~ll  orifice  will  often  lead  the  patient  to  Ink  lightr«fl 


iiMf  1 

1    ■■■^  ;:f|l 


iliiEi 


222 


PRINCIPLES    OP    SURGERY. 


wound,  while  it  may  be  of  the  most  serious  nature.  There  is  no 
gaping,  but  little  pain,  and  unless  an  important  vessel  is  wounded, 
there  will  be  very  little  hemorrhage.  Consequently  the  diagnosis 
is  diflScult  and  the  prognosis  uncertain.  The  wound  is  generally 
both  bruised  and  lacerated,  and  in  places  it  may  be  incised.  This 
will  depend  upon  the  size  and  shape  of  the  weapon,  and  the  force 
with  which  it  entered  the  body. 

Diagnosis. — The  region  of  the  body  in  which  the  wound  exists 
may  assist  in  the  diagnosis.     When  it  is  in  the  abdomen,  particu- 
larly, there  will  always  be  reason  to  fear  that  important  structures 
are  wounded.     Although  the  appearance  of  the  wound  will  not  in- 
dicate the  degree  of  injury,  there  are  other  symptoms  by  which  it 
can  be,  to  some  extent  at  least,  estimated.     There  is  generally  a 
shock  to  the  constitution  when  an  important  viscus  is  involved, 
which  shock  generally  corresponds  to  the  degree  of  danger.    When 
a  bloodvessel  is  wounded,  hemorrhage  from  the  wound  will  make  it 
known,  unless  the  blood  can  find  a  cavity  into  which  to  flow.    If  a 
nerve  be  divided,  a  loss  of  sensation,  will  indicate  the  fact.     The 
size  and  shape  of  the  weapon,  the  direction  it  passed,  and  the  force 
with  which  it  penetrated  the  body,  will,  when  known,  afi"ord  valua- 
ble assistance  in  the  diagnosis.     The  direction  may  be  learned  by 
careful  probing,  yet  this  must  be  done  with  the  greatest  care.    In 
view  of  the  danger  of  causing  further  injury,  by  the  use  of  the 
probe,  it  is  better  practice  to  endeavor  to  learn  the  depth  and 
direction  by  other  means  than  the  probe.     When  it  is  deemed 
necessary  to  use  it,  let  it  be  handled  with  the  gentlest  touch,  lest 
a  vessel  partially  severed  may  be  opened,  or  other  mischief  result. 
Treatment  of  Punctured  Wounds.— The  ordinary  indications 
will  be  pursued.     But  more  than  ordinary  diflSculty  may  be  ex- 
perienced in  stopping  the  hemorrhage.     Of  course,  when  it  is 
within  a  large  cavity,  as  the  abdomen,  it  will  be  beyond  the  reach 
of  the  surgeon.     And  when  it  is  not,  the  small  size  of  the  wound 
and  the  uncertainty  of  its  source  may  cause  much  embarrassment. 
The  blood  wells  forth  in  a  continuous  stream,  but  the  wounded 
vessel  is  hidden,  its  depth  unknown.     In  such  cases  it  has  been 
recommended  to  widen  the  wound  externally  by  incision,  that  the 
artery  may  be  secured.     This  operation,  however,  is  both  painful 
and  difficult.     The  better  course  is  to  apply  direct  pressure,  by 
plugging  the  wound.     The  plugging  must  commence  at  the  bottom 


PUNCTURED    WOUNDS. 


228 


which  clot  will  exoL  rrr!.T  I        '"''""*  ''^  "  "'<"  »f  "»»<!, 
m»8t  bo  colfetnfjLlI^."™  °"'  "■«  P'°S-   The  wound 

."t^r£X:ii'::::i7hir~ .-.  ^he 

to  remove  the  clot  at  f„  eariy  dav  or  I  T  "  ''^"'"'■'■^8'';  »'' 
will  be  to  expose  the  patienM^ TL  dfntrT  "'7' '?'  ""' 
rhage.     Possiblv,  however  so  1  .1      7  secoodary  hemor- 

,»«Y--«on^of  tle^C j;t  dlTr-WhT/tbr  r 
ging  fails  to  stop  the  bleeding   a,  h  .„     .  '^  P'"8- 

con,es  necessary  to  tie  th  I  Z  a  thcT  '  "'  "  ""^  "^ 
as  to  the  precise  spot  whence  tlfe'  huJ«  ^'^'°°  '"'°"'»'  '"'  '""^ 
to  cut  down  on  the  caTdiacVr  r  ,v  °"'  "  "'  ""ommended 
can  be  conveniently  reached  "  "°""''  ^^"'  '"">  ^''^^7 

wo  J  in  order  t^trrrtLetbrr^  ""^''"^  '°  ""•-  '"' 

.he':r:rtro?rf::rr "' j™r  ^ '»""» -  --" 

sinus  may  result     H  aL°r  f '•""'  *'"  "''*"»»'  «"»'  « 

pected  in'  due  courfe  t!  otiThi  T  ^  «""'"^  "=  ''■ 
«u.e  as  for  the  contused  wound  n'  *''t'7'.™"'  ""'  b"  the 
poultice,  in  order  to  kZtZt    I      ^^    "  ^"""'''^'  ">  W^  » 

;ng  .ust  oommencratZtttr  %re:r:e"'r,r  '''' 
free  way  of  escape  for  the  (l„r,I  „,l,  '  "'  '"  '"""»'  a 

depth  of  the  wound.  '     '""""  P"'  "'"  ""'l""'  »  the 

oa.e  bein'g  diligeLuy  Z:!::!''''"''  """"  "'  P™"""'^  -«'  "« 


'   4 


I   If 


^!1 

■  'I 

'I 


irH 


224 


PRINCIPLES    OP    SURGERY. 


CHAPTER  XXVIII. 


Gunshot  Wounds:  History— Division— Missiles— Velocity— The  Kind  of  In- 
jury— Position  of  Body — Location  of  Ball. 

In  considering  this  class  of  wounds  it  is  well  to  include  all  solu- 
tions of  continuity  which  are  produced  by  explosion,  by  which  a 
substance  is  projected,  and  which,  coming  in  contact  with  the 
body,  breaks  the  tissue. 

The  history  of  gunshot  wounds  is  not  uninteresting.  Much 
importance  has  always  been  attached  to  such  on  account  of  their 
associations;  but  in  the  present  work,  where  practical  points  alone 
are  dwelt  upon,  space  cannot  be  given  to  the  subject. 

Divisions.— A  division  of  gunshot,  wounds  may  be  based  upon 
the  causes  of  the  wound,  thus :  1st.  Those  caused  by  explosion  of 
powder  alone.  2d.  Those  by  the  shot-gun.  3d.  Those  inflicted 
by  a  ball,  which  may  be  round,  or  conical.  (In  modern  military 
practice  the  latter  is  more  frequently  met  with.)  4th.  From  a 
grape-shot.  6th.  By  pieces  of  shell.  6th.  Wounds  produced  by 
some  material,  which  itself  has  been  struck  by  a  ball.  7th.  In- 
juries due  to  spent  cannon-balls,  causing  destruction  of  bone,  or 
rupture  of  internal  organs. 

Again,  the  wounds  may  be  divided  into  such  as  are  inflicted 
directly,  and  those  which  are  indirectly  made.  That  is  to  say,  the 
missile  which  inflicts  the  wound  may  be  directly  or  indirectly 
driven  by  the  explosive  powder  against  the  body.  There  are  seve- 
ral circumstances  connected  with  this  division,  which  may  modify 
the  character  and  extent  of  the  wound,  as  well  as  the  eff'ects  upon 
the  constitution. 

Another  division  is  given  in  Holmes's  System  of  Surgery,  based 
upon  the  shape  of  the  body  which  has  made  the  wound.  The  round 
ball  makes  a  wound  mostly  spherical.  The  modern  conical  ball 
produces  a  wound  more  of  a  cylindro-conoidal  shape.  Then  there 
are  wounds  made  by  bodies  of  no  particular  form ;  these  are  de- 
signated irregular.     Such  may  be  due  to  a  bursting  shell,  or  bits 


OUNSHOT    WOUNDS. 


225 


[ind  of  In- 


of  wood  or  atone,  or  iron,  which  have  been  struck  off  f         . 
tures  of  that  material.    Air»;n  .,»  ™  *'""'  ^*""^ 

body  at  the  time  th  wouS  i'.  TT  """"""^  ^^  '■""  ^e 
pieces  of  n.eney,  or\: Zt,7  etn"  '  ^  .f'  "V^^^'  " 
another  individual.  These  unusual TrlXtd  1  "  T 
are  not  cas.ly  diagnosed.    And  when  a.cove:er.t;t:S 

.etr^t-e-tsr:rfwirit^^ 

however,  has  a  less  Tod  ,  'gXTnThe'^-""^-     l'^  "^'«'"> 
cannon-balls  are  eminenllv  l!/    .  ,'"'  '"'  "  ^^e-     But 

great  or  otherwise  ^  destruchve,  whether  the  velocity  be 

the  Lssians  dulTthe  wart  VT"""^"''  ""'  ''■"""'-'  ^y 
Wets  were  found  fbouub"  1^  arnTseSrorb  f  '^^'^ 
juries  received  from  them  h<.^r^  i.  ,  ^eoastopol,  but  no  m- 

fcovery,  pec„li:r."ie's  i:  he  chraclrff^''  "'*°"«''  ""^^  *» 
had  not  previously  been  satisf  ctor  y  aocoun tdT  "°™'''  """"' 
to  have  probably  resulted  from  them    T,  v,T'  '"''P"'^'' 

that  when  discharged  the  dW^rlrV  ""  '''"''y'  '""'ever, 

bullets  were  sufflcfentW tett  ' T  f™'  """'"^''^^  '»'  *«  '« 
which  was  of  very  stlrdtm  .  ^te.^"  T'°'"'  ""''' 
With  the  troops  against  whom  they  ;  rTdXeltd  Dr  'I  ""'"' 
his  History  of  the  Eastpm  p„     -^  .  ^*«  uirected.     Dr.  Scrive,  m 

.li.ryballs'^wereeied  byrr'-"""''!"'  "''°  *''»'  '°'=™- 
small  cylinder  of  com,er   7  .  ""'•     ^'■"^  """''''"d  of  a 

"dmad'e  up  into  tleX;  of    '"'""/  '^'"-"""S  composition, 
discharged  from  „  mlstt     On""!:;'''""'^  ''''"'i"'  «°  -  '»  b 
bums  with  violence      Thte  bail,  w '"*  '"  f'°°'  "''  ?'■">«"'« 
oonolasion  of  the  si  .e  and  it  w       T  T'  '''""™  ''"  ""'^  ^e 
'ha'  a  key  was  obtS   o   olToS  If""'  ^^  f/'^  '™"'=^' 
"hich  could  not  be  accon„..r    TTu  "  '"«'"'^"'  character, 

or  fragments  of  shell."  ^  *'  ""''^  "^  ""'■-"y  k-Uet^, 

^^«e  Influence  of  Velocitu      A  „  i.     i 
much  to  do  in  giving  challTM,  ,'■'''  "'«»  ""™'"cd,  .rfo^Vy  has 

-e.    XheLl,  ttXCirrreSr^^^^^^^ 

Ifl 


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Im 

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1 

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-IJIl 

il . 

HI' 

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1  1 

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Iwl 

226 


PRINCIPLES    OF    SURGERY. 


death-errand  for  a  distance  of  1000  yards,  will,  in  the  first  part  of 
its  course,  prove  far  more  destructive  to  tissue  and  to  life  than  did 
the  old  rifle-ball,  which  could  take  no  effect  beyond  250  yards. 
And  the  musket-ball,  being  round,  will,  when  going  with  its  great- 
est speed,  cut  the  tissue,  without  a  serious  amount  of  bruising  or 
tearing ;  but  the  conical  ball,  perhaps  in  consequence  of  its  shape, 
but  more  likely  from  the  boring  manner  in  which  it  passes  through 
the  tissue,  produces  a  great  deal  of  injury  to  it.  That  is  to  say, 
extreme  velocity  in  the  round  ball  lessens  the  degree  of  danger, 
while  in  the  conical  ball  it  increases  it,  whether  it  strikes  the  soft 
or  hard  tissue.  The  following,  as  to  the  contrast  between  the 
effects  of  the  old  fire-arms  and  those  in  use  at  the  present  time, 
will  be  found  interesting  and  instructive : 

"  The  velocity  of  motion  of  different  projectiles  is  an  important 
ingredient  in  the  consideration  of  the  several  wounds  produced  by 
them      The  rates  of  motion  imparted  to  missiles  by  the  fire-arms 
of  early  times  were  probably-from  the  imperfect  construction  of 
the  weapons,  defective  quality  of  gunpowder,  and  other  circura- 
stances-as  inferior  to  those  of  the  musket  lately  in  use  as  the 
velocity  of  musket-balls  was  to  that  of  the  conical  bullets  of  the 
rifles  in  present  use.     In  a  table  showing  the  velocities  of  certam 
moving  bodies,  published  in  1851,  the  common  musket-bullet  is  set 
down  as  moving  at  the  rate  of  850  miles  per  hour ;  the  rifle-ball 
of  that  time  at  1000 ;  the  24-pound  cannon-ball  at  1600  miles  per 
hour      But  the  musket-ball  then  could  not  be  depended  on  to  hit 
an  object  beyond  80  yards,  the  rifle  200  to  250  yards;  while  the 
present  Enfield  rifle  is  sighted  to  900  yards,  and  the  short  Enfield 
to  1100  yards.      The  effects  of  different  rates  of  velocity  on 
wounds  are  seen  in  the  variations  which  occur  in  proportion  to  the 
distance  which  the  missile  has  travelled  before  inflicting  the  injury. 
A  cannon-ball  which,  with  but  slight  velocity  of  motion  added  to 
its  weight,  would  knock  a  man  over,  at  ordinary  speed  will  carry 
away  a  limb  without  disturbing  the  general  equilibrium  of  the 
body      A  musket-ball  that  would  be  arrested  half  way  through  a 
limb,  is  now  replaced  by  a  ball  which,  at  like  distance  from  the 
point  of  discharge,  will  pass  through  several  bodies  in  succession 
-  The  increased  velocity,  or,  in  other  words,  greater  force  of 
modern  projectiles,  exhibits  its  effects  in  two  directions:  local y, 
by  the  greater  destruction  of  tissues  in  the  track  of  the  projectile; 


GUNSHOT    WOUNDS. 


227 


organized  fabrio^hrJ^V:^  nirV  'f"  P-''»»  "^  the 
several  miles  per  minute  Z,.      .         '  '"'^'''"'"g  »'  the  rate  of 

of  their  viealif,.  ""in-^ctr  '  LTeTbT  '"r""^/^^^''^^ 
wounds  having  healed  bv  simnll    ?u  ^    """'"•  "'  g"""!!"' 

not  met  ^tk  tZ  mZL  T'-'^'  •>»' «"* -^-Ples  are 
Moreover,  .hen  eonsideri„!th  1     '?7  ^"  °"«'"»'  f"™- 

it  wn,  have  to  be  aho  J'tlt'^lrXc"!"  tS'^:  ''^-  ^"1^' 
from  modern  weapons  has  Ud  t„  '{  ™Parted  to  projectiles 
wounds.     The  great  power  of  lit   """"'■•/■•auge  in  gunshot 

b.  the  yieidi„g%,a,/;:if„~i:ir;:t"d''^'"^  ""■"■'"" 

structures,  is  no  longer  of  avail  „l,  .  •>?  «ond,noas  and  other 
«re.arms,  at  their  ust,  rLrof  s^::^    '™^"'""  '™"'  "»»"- 

shroVttgt  jriTtrer*'."^  "°"'"^'  ^'"» «» •»« 

mentioned  when  referring  tothelr'"'-''''  '"'™  "'^'^y  '«<"' 

together  with  form,  theroutoCrrifr"'""''^-  ^°'' 
gredient  m  estimating  this  result     ",    "  ,  "^  '»  ">  necessary  i„. 

from  their  form,  but  also  from  ,1,  1  """"^  Wls.-par.ly 

firelocks  from  wWch  they  wl -e  di  cLr";*"^  ""'"'■■'™  "^  "■» 
degree  of  velocity  ™P»Ld  ^^^  t^it  Tt  iCrr^"'  --' 
™ply  be  turned  away  from  the  direc  line  •  or  f2„  T'  """''' 
knock  out  a  portion  of  thn  ,l„ft      -.7      /'      ""«  ""*'  ™nl<I 

having  perforated  on  one  sTderel-"."'  '■"""'  ^"^""'''  <". 
or  be  simply  flattened  wi  h  ^eTe  ^t^  "'%r  "''"'^'  "'"*-^^ ' 
also,  that  the  modern  conical  ImI  \  '""""  "»'  """'"''y. 
»tance  of  their  manufacture  by  tln^™'^^'  '""^  «■>»  »-- 
such  as  are  still  used  in  some  °f,  "'"""'"'!'''  Pressure,  than  bullets, 
«f^o„sity,withresprr   :;^\7;':-*    Theinfluenee' 

wben  lead  is  «sed,Ve "  n  t™^l tS  v^f  "'  "^  T '  "''•«-'• 
w.th  the  Whitworth  than  the  EnfieM  Iff  1  «»o-third  greater 
joctile  is  used  (as  when  the  lc..l  s  mi^rl  th't  ?■  """'"'  ^"^ 
"  as  17  to  4  at  800  yards     W  ,mU    ,t  ""^'  "»  P^otration 

'bo  fact  is  certain  that  c„„iea7b„t  ■  """  "''""^^  ^  "<». 

mbly  an  overpowering  ?  c    °„ tr  "  r  l™  ^''''■''■"""■ost  inva! 

eluded,  with  which  they  come  11  ""'''*.»"•»"'"■•«».  bone  in- 
">ey  come  into  contact  m  the  human  body, 


I     !.' 


I     i 


i 


^ 


''  j 

Itfj 

i  1 

^^ffi' 

1   i 

i  ■    ■ 

228 


PRINCIPLES    OP    SURGERY. 


and  are  rarely  met  with  flattened,  or  so  much  altered  in  form,  as 
bullets  not  unfrequently  were  formerly  under  like  circumstances." 
(Prof.  Longmore,  Syst.  Surgery.) 

Another  kind  of  injury  is  that  arising  from  a  spent  cannon-ball. 
It  is  not  due,  as  formerly  supposed,  to  the  concussion  of  the  air, 
but  to  the  weight  of  the  ball,  which  rolls  along  with  only  sufficient 
momentum  to  overcome  the  force  of  gravity.  A  body  lying  upon 
the'ground  will  not  arrest  its  progress,  but  the  ball  will  roll  over  it. 
If  it  be  a  leg  or  arm,  the  bones  will  be  crushed  by  its  weight;  or 
if  it  be  another  part  of  the  body,  life  may  be  destroyed.  The 
most  extraordinary  feature  is,  that  the  skin  and  other  soft  tissues 
are  often  entirely  uninjured.  Tissues  that  will  yield  under  the 
weight  will,  as  a  general  thing,  escape.  For  instance,  a  ball  roll- 
ing over  the  abdomen  may  produce  rupture  of  the  liver  or  other 
viscera,  while  the  walls  remain  unaffected. 

Upon  the  velocity  will  also  depend  whether  the  missile  lodges 
in  the  body,  or  completely  traverses  it  and  escapes.     When  the 
speed  is  limited  in  degree,  the  tissues  of  the  body,  especially  the 
bone,  will  arrest  the  missile,  causing  it  to  lodge  in  the  body.    The 
modern  Mini^  and  Enfield  balls  travel  with  great  swiftness,  and 
consequently  lodgment  is  not  so  common,  relatively,  as  was  for- 
merly tiie  case.     In  a  letter  to  the  London  Lancet,  written  after  a 
visit  to  the  military  hospitals  in  and  about  Washington,  in  Decem- 
ber 1862,  I  wrote  respecting  this  subject,  as  follows,  speaking  of 
a  museum  which  was  in  preparation  at  Washington,  consisting  of 
dried  specimens  of  wounded  bone :  "  The  bones,  being  thoroughly 
cleaned,  are  arranged  with  much  skill  on  wires,  so  as  to  show  the 
manner  in  which  the  ball  had  entered,  the  effects  immediately  pro- 
duced, and  subsequently  the  efforts  made  by  nature  to  repair  the 
injury.     By  this  means,  it  is  clearly  demonstrated  that  the  Mime 
ball  is  but  rarely  turned  aside  by  the  bone;  and  that,  although 
the  ball  is  generally  much  battered,  it  will  pass  through  even  the 
largest  bone,  or,  if  the  momentum  be  not  very  great,  it  will  bury 
itself  in  the  osseous  tissue.     In  every  instance,  the  bone  was  seen 
more  or  less  comminuted,  even  where  the  ball  had  seemingly 
passed  through  the  bone  with  considerable  force.     From  looking 
at  these  specimens,  it  would  appear  as  if  the  cone-shaped  ball 
passed  into  the  bone  in  a  wabbling  manner,  and  that  thereby  great 
destruction,  characteristic  of  that  ball-wound,  is  accomphshed. 


GUNSHOT    WOUNDS. 


229 


located  in  a  place  most  unexpected      in  «    l       .  ""''  """^ 

would  seem  to  have  taken  a  vCt"  .l? X'"  ^f  -^J""  !' 
is  the  round  ball,  mjy  be  attrihm.hL  .T  ''  "'"'"  " 

to  turn  it  .side;^„t'it  r2e ;:'  X  /ueTtr  "■•  v°"°  '" 
.ion  of  the  body  at  the  ti.e  thetrnters  il'"  ""^  """"^^  ^''■ 

stretched,  of  fle/ed  ^rd  ffe  t  Z  ^  Td  Th  ?7  "^^'^ 

conflict  the  soldier  will  necessarilv  h.  .7, '  """""^  ** 

ble  attitude,  while  the  enemv  ™  I  «  V-"  ''"^  '=»'"'^'™- 

directions,  St  can  be  reTr/u:  L  rodX"'':  'T  '''"T 
body  be  wounded  in  any  part  but    he  b.l  ^  """^  *' 

reotion  through  the  body  or  hmb  A^t^  i  ,7^  ?"'"  '"  """■^  <"■ 
burg  there  wfre  a  cert^  IbeV  „t„t  Xed  "'  ''"'"'"'"■ 
position.     This  was  done  durinTthr  nl'ht       d'l"  T  """"' 

"JXii^::  TLtosirr-  r^r-  "  =' 

now  and  L„,  when  the  head  of  i"  .^  '^"""«  *<'  ''"y-  ""<• 

slightest  extent  fron,  the  tlnl  "f  jf  ""'"'"'  "'""  '»  *^ 
nan.    The  result  wa,  T ,     ,      '  ""  "  '"'S*'  f"  ""^  rifi<=- 

be.d,face,r:'and   „li:onrecrt'''''r™  """'"^  '"  *^ 
had  traversed  the  neck  obluel  %      t  7"  ""'''  ""^  '"" 

■e.  With  the  body,  and^rrtr^raTardlt^  ^"'^"  -"'• 
inflicted  several  wonnl      n  Sometimes  the  same  ball  had 


i    1 


Nt! 


230 


PRINCIPLES    OF    SURGERY. 


while  in  the  act  of  putting  a  cartridge  into  his  musket.  The  ball 
had  completely  cut  off  his  forefinger,  then  passed  directly  through 
the  body  of  the  hand,  and  again  entering  the  back  of  the  arm, 
about  two  inches  above  the  wrist,  had  ploughed  a  furrow  for  a  few 
inches,  and  then  entering  into  the  deeper  part  of  the  arm,  had 
finally  made  its  exit  and  escape  a  little  above  the  external  condyle 
of  the  humerus.  Now,  it  can  be  at  once  understood  from  the  fore- 
going, that  when  the  ball,  instead  of  making  its  escape  from  the 
body,  remains  within  it,  it  will  be  exceedingly  difficult  to  ascertain 
its  locality.  Not  only  may  the  ball  be  lodged  in  a  part  very  re- 
mote from  its  place  of  entrance,  but  chance  may  have  taken  it  in  one 
direction,  or  perhaps  the  opposite.  It  will  be  impossible  to  tell  its 
course  unless  its  track  can  be  traced  externally,  or  the  patient  can 
call  to  mind  the  position  he  was  in  at  the  time  he  was  wounded, 
and  the  direction  the  ball  came;  but  then,  even,  it  may  be  impos- 
sible to  say  whither  it  has  passed. 

The  difficulty  of  ascertaining  the  locality  of  a  ball  is  increased 
by  the  fact  that  its  own  weight  will  often  lead  to  displacement 
from  the  first  place  of  lodgment.  And,  also,  the  contraction  of 
muscles  may  cause  it  to  move  to  some  extent.  Not  only  do  balls 
lodge  in  the  body,  but  also  any  one  of  the  missiles  which  produce 
gunshot  wounds  ;  such  as  pieces  of  shell,  or  stones,  or  bit  of  wood, 
or  a  button,  or  a  piece  of  clothing,  or  even  a  comparatively  large 
grape-shot.  Several  interesting  cases  are  recorded  in  the  System 
of  Surgery,  by  Holmes,  where  a  grape-shot  had  unexpectedly  been 
found  lodged  in  the  body.  And  I  have  now  before  me  one,  not 
very  large,  which  was  excised  near  the  spinal  column  between  the 
scapula).  It  had  entered  behind  the  left  shoulder  and  passed 
beneath  the  scapula. 


/ 


SYMPTOMS    OF    GUNSHOT    W 


OUNDS. 


231 


iTSi^t 


CHAPTEE   XXIX. 

Sympton^s  of  Gunshot  Wounds-Treatment:  Local-General-Pn™.ry    or 

Secondary  Operations. 

S!/mpU,n,.  of  ff„,te  Wounds.-Vo  have  to  consider  those 
tha.  present  themselves  in  the  part,  and  those  .hich  affect  the 
whole  constitution. 

.)Il\^'""'-l  ^"'"P'""'  "^  '"  "^-y  aspects  the  same  as  those 

™nds.     The  characteristics  are,  generally,  much  crashing  of 
l.s»ue,  and  very  often  considerable  tearing  of  the  structures.    The 
conical  ball  especially,  boring  its  «y  through   the  tissue    i 
emnently  destructive  to  it,  vitality,  and  aIo„g%hc  rtol    of  i 
course  w,ll  be  found  a  lining,  of  tissue  so  injJed  .hat  it  wU  in 
e    ably  per,sh.     The  effects  of  the  round  ball  upon  the  tissue 
dtLcXm'.'"  ""-'  "'^"''  "r»»  '"»  -'-"^  »f".e  ban  as"! 
Pam  may  be  almost  or  altogether  absent.    It  is  characteristic 
of  gunshot  wound,  that  the  pain  does  not  altogether  deprupn 

t'iZtJ'''"''  r  '""'"°"  '°  "''""  -"-  have'  becnTx" 
po»ed  but,  to  a  great  extent,  upon  the  temperament  of  the  indi- 
v.dua ,  and  the  state  of  mind  in  which  he  was  at  the  time  the 
wound  was  inflicted.  So  true  is  this,  that  the  soldier  m»rbe  se 
mu  ly  wounded,  and  yet  be  unconsciou,  of  the  fact.  Wrought  up 
to  the  h.ghct  pitch  of  excitement  by  the  engagemeri  and  th^ 

«~:::  «i[rr  ""-"'■  - '""''''™-  --- '  -y  i'::!' 

rece  ved,  and  ,t.ll  the  recipient  rush  on  in  the  bloody  strife 
Wlnle  on  the  other  hand,  where  fear  is  predominant,  thcTst  rj^y 
from  the  enemy  may  cause  the  sensitive  one  to  fall  down  "m^ 
pr«ed  with  the  belief  that  a  do«n  balls  have  pierced  him     Aid 

Tf Xui'l'n ''•'T' "':'"  ""'" ""' '■^'""^ »  """•i» ^'  « 

l?r.    .  ■""'"""•     ^'■o  -=i'-'=™»tances  of  c.n.„.|if„  mav 

b  "ved  a  T"""  '-'■"—•  Whatever  be  the^'ca  ,  ,  ^ 
Observed  a  good  many  woundcil  on^a  «,„ r  .i. ...     ,. ', 

-  "- 7  —-''J  VI  lucui  wun  sngnt 


t 
'  1  r 


*   t 


y 


M 


j 


232 


PRINCIPLES    OP    SURQERT. 


wouncis,  yet  who  suffered  excruciating  pain,  while  others  experi- 
enced but  little. 

Hemorrhage  is  not,  as  a  general  thing,  very  great.  The  fact 
that  the  wound  is  lacerated  and  bruised  would  promise  the  absence 
of  bleeding.  We  have,  however,  the  testimony  of  the  experienced 
Guthrie,  that  hemorrhage  is  often  considerable. 

But,  while  the  primary  hemorrhage,  it  may  be  said,  is  not  com- 
mon, secondary  hemorrhage  is  very  likely  to  occur.  The  injured 
state  of  the  tissues  necessitates  the  process  of  ulceration  at  least. 
( Vide  Lacerated  Wounds.)  Attending  this,  will  be,  to  some  extent, 
the  inflammatory  process.  This  will  often  lead  to  the  opening  of 
vessels.  The  ball  in  its  passage  impinges  on  arterial  coats,  affect- 
ing their  integrity;  and  subsequently,  the  process  of  ulceration 
sequestrates  the  injured  portion  and  thereby  opens  the  arterial 
tube,  and  bleeding  is  the  consequence. 

Gaping  is  not  very  great  in  gunshot  wounds.  Oftentimes,  on 
the  contrary,  the  lips  are  inverl;ed,  especially  where  the  ball  had 
entered,  and  where  it  emerged  there  is,  at  least,  an  absence  of 
gaping,  so  that  very  frequently  the  orifice  is  seemingly  less  than 
the  size  of  the  ball. 

But  although  the  wound  at  the  place  of  entrance  is  often  charac- 
terized by  inversion  of  the  lips,  yet  such  is  not  always  the  case. 
After  considerable  attention  to  the  matter,  and  careful  observa- 
tion, I  have  to  say  that  there  is  no  regular  order  concerning  the 
relative  size  of  the  orifice  of  entrance  and  of  exit.  I  have  fre- 
quently seen  the  wound  where  the  ball  emerged,  even  smaller  than 
that  made  by  its  entrance.  Sometimes  the  ball  will  travel  some 
distance  immediately  beneath  the  skin,  and  its  course  will  be 
marked  by  a  somewhat  livid  mark.  By  passing  the  finger  along 
the  route  a  sensation  of  crepitus  will  often  be  experienced. 

Constitutional  Symptoms. — The  first  is  the  well-marked  shock. 
Sometimes  it  is  slight,  but  more  frequently  it  is  very  great.  No 
doubt  this  is  due  in  part  to  the  circumstances  of  battle,  and  to  the 
actual  shock  imparted  to  the  nervous  system.  I  have  repeatedly 
asked  those  who  had  been  struck  with  a  ball,  as  to  the  nature  of 
the  sensation  at  the  moment.  As  before  said,  some  are  not  even 
aware  of  the  fact,  until  weakness  or  helplessness,  or  the  loss  of 
blood  acquaints  them  with  it.  Those  who  could  call  to  mind  the 
sensation  when  wounded,  described  it  as  something  resembling  ft 


SYMPTOMS    or    GUNSHOT    WOUNDS.  233 

generally.  The  prostration  consequent  thereupon,  is  sometime 
very  grea  and  alarming.  Of  course  when  an  infpo  tant  t™Z 
.8  involved,  the  shock  will  be  correspondingly  great. 

Other  constitutional  symptoms  will  supervene.     These  mav  be 
due  to  loss  of  blood,  or  exhausting  discharge,  or  locrirrTtation 
or  want  of  rest,  or  imperfect  diet  or  nursing.     Then    h  re  are  a 
variety  of  complications  which  often  present  themselv    ,  as    fo^ 
instance,  pyemia.  '      '    ^ 

The;,™^„„„-,  of  gunshot  wounds  should  always  be  exceediuBlv 
cautious,  more  especially  when  the  shock  is  severe,  or  there  is  rea 
son  to  fear  that  deep-seated  parts  are  involved ;  a^d  also  f  om  the 
fact,  just  above  stated,  that  serious  constitutional  complica"   ns 
may  supervene.  "ipucttuons 

Treatment  of  ann,hct  lr»«*,_The  loeal  treatment  will  be 
somewhat  mod.  led  according  as  the  wound  partakes  of  the    ha 
racer  of  the  incised,  the  lacerated,  the  bruised,  or  the  punctured 
t  IS  scarcely  necessary  to  say  that  it  is  desirable  to  have  tl« 
oreign  body  removed.     With  respect  to  balls  which  may  have 

be  removed^    Formerly,  ,t  was  recommended  to  take  no  great 
ro*  to  effect  their  extraction  ;  but  according  to  recent  praftce 

Sjst  Surgery  )  But  more  generally  the  foreign  body  is  a  con- 
tmued  source  of  irritation,  pain,  and  danger.  Thi,  .ilV  ° 
.r^nenaei  «,/.„  tU  position  of  the  lall .' Wn;  b  :  en  i.  L' 
not,  ,  becomes  a  question  how  far  efforts  should  be  mad!  1  r„ 
U.  whereabouts  by  probing.  A  wound  may  bo  probed  by T 
metalhc  probe,  or  by  the  finger.    According  to  the  high  author  y 

i;°'r:%'?r'™,°'.'r''"^''  "  ■»  P-f-able'to  u,e  t  « 
linger.  But  if  the  probe  is  handled  with  great  gentleness  a,  tho 
probe  ought  always  to  be  used,  it  is  less  likely  to  eaule  rH  „,  o" 
and  extend  the  depth  of  the  wound.     I  cannot  omit  cxnre  sTnl  ° 

the  ball  ,s  lodged  are  too  often  subjectci  to  rough  examination 
M,  w,     the  prol,,.  and  the  finger.     It  is  a  question,"  ::": 

a.lvantage  to  bo  obtaniod  by  probing  1,  commensurato  with  the 


11! 


iStI 


-iJl 


234 


PRINCIPLES    OF    SURGERY. 


risk  of  forcing  the  probe  into  unbroken  tissue.  Not  a  few  cases 
came  under  my  notice  while  in  the  United  States  service,  in  which 
pyemia  and  death  ensued  after  the  use  of  the  finger  to  discover 
the  ball,  although  the  patient  did  not  seem  to  be  predisposed  to 
such  diseases. 

Before  commencing  to  explore  the  track  of  a  ball,  the  patient 
should  be  placed,  so  far  as  it  can  be  known,  in  the  position  he  was 
when  wounded ;  otherwise,  the  channel  will  be  obstructed  by  the 
relative  change  in  the  position  of  structures.  The  ball  will  some- 
times be  buried  in  the  bone,  in  which  case  all  efforts  to  remove  it 
will  prove  useless  ;  and  occasionally  it  will  remain  without  causing 
any  inconvenience  or  irritation.  Should  it  produce  irritation  that 
will  lead  to  a  separation  of  it  from  the  bone,  then  it  can  easily  be 
extracted.  The  instrument  with  which  removal  is  effected  is  very 
commonly  the  bullet  forceps.  Objection  is,  by  some,  made  to 
these,  because  of  the  necessity  of  separating  the  blades  to  grasp 
the  ball.  Professor  Longmore,  of  the  Military  School,  Netley, 
recommends  the  extractor,  consisting  of  a  scoop  for  holding,  and 
central  pin  for  fixing,  the  bullet. 

There  is  a  possibility  of  being  too  solicitous  to  extract  the  ball. 
Of  two  evils,  the  surgeon  ought  to  choose  the  least ;  and  while  the 
ball,  as  any  other  foreign  body,  ought  to  be  removed,  it  should 
not  be  forgotten  that  the  efforts  to  remove  it  may  be  productive  of 
more  evil  than  the  ball  would  be  if  left  to  nature.  Protracted  and 
violent  efforts  cannot  be  recommended  in  any  case.  Before  search- 
ing for  a  ball  in  the  wound,  careful  examination  ought  to  be  made, 
with  the  hope  of  detecting  it  in  some  subcutaneous  position,  as  in 
such  cases  it  will  be  preferable  to  make  a  direct  incision  upon  it. 
Very  often,  although  not  always,  the  patient  will  become  aware  of 
its  position  by  pain  or  uneasiness  in  the  part ;  perhaps  not  at  once, 
but  after  a  few  days.    One  case,  which  just  comes  up  in  my  mind, 

I  will  give  as  an  illustration.     Sergeant  C had  been  wounded 

in  the  leg,  I  think  while  advancing  at  the  double-quick.  The  ball 
had  entered  to  the  front  of,  and  a  little  below,  the  knee.  It  was 
a  fortnight  afterwards  when  he  came  under  my  care.  In  the  mean 
time,  the  wound  had  been  repeatedly  probed  in  the  efforts  to  find 
the  ball,  but  without  success.  Believing,  from  the  character  of 
the  wound,  that  the  ball  hud  taken  a  downward  course,  I  proceeded 
to  carefully  examine  the  leg  on  every  side.     Coming  to  the  ankle, 


TREATMENT    OP    SUNSHOI    WOUNDS.  238 

a»d  while  pressing  .he  finger  inward  heneath  the  fendo-AchiUis 
near  us  attachment,  he  complained  of  soreness,  and  at  the  sal 
t,me  I  could  d,stmctly  feel  a  hard  substance.  The  patient  assured 
that  th,s  must  be  the  ball,  submitted  at  once  toC  u se  f  he 
kn,fe  and  a  large  Mini6  ball  was  extracted  through  the  wound 
It  had  not  caused  so  far,  any  inflammation.    The  bafl  was  shghtlv 

when  the  .0..  ml  l^lTr^^lZZZ!' ^^^^^^^^^^^ 
no  only  more  than  a  foot  from  the  place  of  entrance,  buUt  w 
1  0  at  the  opposite  side  of  the  limb.    Moreover,  the  bill  had  blen 

S  which?  '"  I""'  '"*°'"  "^^""8  -fl-™tion,  a  d     : 
wound  which  was  made  to  remove  the  ball  healed  in  a  few  days 

dia/n  sirThav    r  """'  ""^  """''  "■"'*  "»  "^"^■"  "'  his 
diagnosis.    I  have  known  an  incision  to  be  made  upon  the  exter- 

n.   condyle  of  the  humerus,  with  the  belief  that  1'  was  a  bal 

Other  foreign  bodies,  such  as  bits  of  eioth,  or  a  button,  wil    be 

removed  when  discovered ;  but  the  rules  of  procedure  a  e"  „„ 

way  different  from  those  detailed  in  connecLn  with  punctured 

the  principles  are  the  same  as  those  given  before.    It  will  be 
borne  ,n  mmd  that  the  surrounding  tissue  has  been  much  in  Id 
and  that  time  will  be  required  to  establish  the  line  of  divi  "on  be! 
tween  the  tissue  which  can  recover  and  that  which  will  perrh 

Conrntufonal  Treatment  of  Qun.Lot  Wound.-lTlZ &^t 
place,.t  IS  not  unimportant  to  state  that  great  care  is  essential^ 
removing  a  wounded  man  from  the  field.  The  surgeon  rcalled  a 
non-combatant  officer,  sometimes  in  offensive  tonf;  b  h  wil 
ngly  goes  on  the  battle-ground  while  the  conflict  rages,  to  relie  e 
the  distressed,  to  succor  from  death,  while  he  has  not  the  excite 
njent  to  sus,.i„  him  which  the  officer  in  command  e  e  f  a  few 
«n  has.     Under  sueli  circumstances,  it  will  often  be  impossibll 

•ns  bTtl    "  ''°°°''"'  ■"""  """  '"  "™'  '■■«  l.on,„rrhag  ,  P 
haps  by  temporary  means.     There  is  commonly  a  place  ff  com 

ltd  ^life':  ''Tr' '""-  ^''--y  "p-tirns^hici,:: 

.In-ii,  ■  ^''  O"'""".  recommends  a  kind  of 

wheelbarrow  as  the  most  suitable  vehicle  to  use,  and  which  can  bo 


PI 


i    I  8 


H 


w. 


'  1'IFi 


236 


PRINCIPLES    OF    SURGERY. 


I  i* 


managed  by  one  person.  The  surgeon  upon  the  field  will  see  the 
wounded  comfortably  placed  upon  the  stretcher,  taking  a  part  to 
save  any  limb  that  may  be  injured  from  unnecessary  motion. 

Inasmuch  as  there  is  generally  prostration  from  the  shock,  and 
the  work  of  restoration  will  be  attended  by  nervous  irritation  and 
exhausting  discharge,  the  powers  of  life  must  be  from  the  first 
husbanded,  or  perhaps  supported.  If  antiphlogistic  measures  be 
required,  they  ought  to  be  adopted  with  caution. 

The  question  will  often  have  to  be  decided,  in  a  practical  way, 
whether  primary  or  secondary  amputation  should  be  performed. 
In  a  communication  to  the  London  Lancet  in  1863,  after  having 
inspected  some  thousand  cases  of  wounded,  and  heard  the  opinion 
of  several  surgeons,  competent  to  judge,  in  the  American  war,  I 
expressed  the  following  opinion : 

"Although  a  strong  advocate  of  conservative  surgery  in  the 
broadest  sense  of  the  term,  I  became  convinced,  that,  upon  the 
field,  amputation  was  less  frequently  resorted  to  than  it  should  be; 
that  while,  in  a  few  cases,  the  operation  was  unnecessarily  per- 
formed, in  many  cases  it  was  omitted  when  it  afforded  the  only 
chance  of  recovery.  The  Mini^  ball,  when  it  strikes  a  bone,  pro- 
duces extensive  comminution ;  while  all  along  the  track  where  it 
has  passed,  in  the  soft  parts,  there  is  a  good  deal  of  destruction  of 
tissue.  Now,  if  absolute  rest  could  be  secured  to  the  patient,  in 
many  cases  nature  would  be  adequate  to  effect  repair ;  but  the  cir- 
cumstances of  war,  the  frequent  and  in  many  cases  careless  re- 
movals to  which  the  wounded  are  subjected,  preclude  the  possibility 
of  recovery  under  the  care  of  the  most  judicious  surgeon.  In 
very  many  cases,  were  primary  amputations  practised,  the  system, 
rid  of  a  great  source  of  irritation,  would  safely  endure  the  subse- 
quent disturbance.  Perhaps,  in  injuries  involving  the  leg,  and 
more  especially  the  (knee  and)  thigh,  such  proves  more  generally 
to  be  the  case."  I  saw  not  a  few,  upon  whom  secondary  opera- 
tions were  performed,  and  who  subsequently  died;  but  had  the 
operation  been  resorted  to  at  first,  the  life  would  have  been  pre- 
served. 


ii 


POISONED    WOUNDS. 


237 


CHAPTER   XXX. 

Poisoned  Wounds-Three  Varieties._(l)  Dissecting  Wounds-Symptoms- 
Treatment.— (2)  Stings,  &c. 

Poisoned  Wounds.^Sipeaking  generally,  by  a  poisoned  wound 
IS  meant  the  introduction  of  a  poison  into  the  system  through  the 
wound  at  the  time  it  is  inflicted.  But  it  is  necessary  to  include 
under  this  term  all  wounds,  or  sores,  or  abraded  parts,  which  may 
have  been  poisoned  by  the  contact  of  the  virus.  And,  even  more 
than  this,  It  IS  desirable  to  include  also  those  cases  which,  although 
the  wound  or  sore  is  not  directly  poisoned,  become  so  by  the  poi- 
son being  otherwise  imbibed  by  the  system,  as  when  the  cuticle  is 
very  thm,  or  when  a  part  is  for  a  long  time  exposed  to  the  poison, 
or  when  the  poison  is  very  virulent. 

Sources  of  Poison.~mson  maybe  derived  from  a  mineral  a 
vegetable,  or  an  animal  source.  It  is  the  last,  where  the  poison 
IS  of  animal  origin,  that  we  have  here  to  consider.  This  may  arise 
from  different  sources.  1st.  From  dead  animal  matter,  which  is 
undergoing  decomposition,  or  about  to  do  so,  as  from  the  dissec- 
tion ot  a  body,  or  from  making  a  post  mortem  examination.  2d 
From  a  healthy  living  animal  whose  bite,  or  sting,  is  naturally 
poisonous  to  the  human  system,  such  as  bites  of  serpents,  sting  of 
bees,  &c.  3d.  From  a  diseased  living  animal,  which  may  be  com- 
mumcated  l?y  a  bite,  or  by  inoculation;  of  these  we  have  hydro- 
phobia, glanders,  &c.  "^ 

Dissection  Wounds—With  respect  to  the  first  of  these  three 
classes,  the  most  important  is  the  Dissecting  Wound.  This  poison 
may  be  rom  the  dead  animal  matter  of  the  body  which  is  being 
dissected,  or  examined;  or  it  may  be  a  poison  which  had  been  del 
veloped  in  the  system  prior  to  death,  and  which  probably  had 
caused  It.  In  the  latter  case  the  virus  is  more  potent,  and  the 
rosult  more  likely  to  prove  fatal  if  the  poison  be  received  soon 
after  the  death,  than  it  will  after  some  time  has  elapsed.  This  is 
especially  so  m  puerperal  peritonitis. 


]i 


238 


PRINCIPLES    OP    SURGERY. 


Division. — There  are  two  general  forms  of  dissecting  wounds — • 
acute  and  chronic.  The  acute  is  rapid  in  its  course,  and  mostly 
fatal  in  its  termination.  The  chronic  is  generally  mild  in  its  na- 
ture, and,  although  tedious,  not  often  fatal. 

Mode  of  Introduction. — The  modes  of  introduction  into  the  sys- 
tem are  two — one  general,  the  other  local.  The  general  cause 
may  predispose  for  the  local  cause ;  that  is  to  say,  the  system  may 
become  gradually  affected  from  long-continued  dissecting,  or  ex- 
tended exposure  to  the  poisonous  air  of  a  dissecting-room,  which 
not  only  affects  through  the  lungs,  but  also  by  the  skin.  And  an 
individual  with  the  system  thus  contaminated,  if  wounded  by  any 
instrument,  will  very  likely  have  all  the  symptoms  of  a  dissecting 
wound.  It  is  not  necessary  that  the  poison  should  be  introduced 
by  a  wound  made  in  the  dissecting-room.  Any  wound  from  any 
cause,  or  a  local  inflammation  from  any  cause,  is  quite  sufficient 
to  give  rise  to  the  disease.  The  system  being  poisoned,  and  a 
part  becoming  injured,  instead  of  the  healing  process  being  com- 
menced and  carried  on  as  in  health,  inflammation  of  a  specific 
character  ensues. 

A  wound  may  be  received  while  in  the  dissecting-room,  and  the 
poison  actually  coming  in  contact  with  the  divided  tissue,  be  at 
the  time  received  into  the  system ;  yet  had  there  not  previously 
been  contamination,  the  local  reception  would  not  have  led  to  the 
train  of  symptoms  which  follow.  Indeed,  many  of  the  local  symp- 
toms are  often  due  to  the  previously  poisoned  state  of  the  blood. 
Those  students  who  most  frequently  contract  the  disease,  are  they 
who  have  for  a  long  time  been  dissecting;  while  the  one  who  has 
but  recently  entered  upon  that  part  of  medical  study,  may  cut 
himself,  if  in  health,  with  impunity.  In  those  cases  where  the 
disease  was  seemingly  due  to  the  imbibition  of  the  poison  through 
a  recent  wound,  it  will  very  often  be  found  that  some  other  pre- 
disposing cause  had  been  in  operation,  and  that  the  disease  arose, 
not  so  much  from  the  dissecting  wound,  as  in  consequence  of  con- 
stitutional depravity.  A  system  vitiated  by  the  existence  of  any 
poison,  or  weakened  from  any  cause,  is  thereby  rendered  liable  to 
attacks  of  this  disease,  if  a  wound  happens  to  be  inflicted.  Under 
such  circumstances  the  work  of  repair  cannot  proceed ;  initiatory 
steps  may  bo  taken,  but  they  come  far  short.  It  is  indeed,  a  dis- 
ease of  the  healing  process. 


POISOHED    WOUNDS. 


239 


The  0  mectrng  »„„„a,  or  a  wo«nd  in  connection  with  the  noi 

the  s,ste/,  the-intenfit*:;!  ^I^^^ITZ  " 
tare  of  the  wound,  whether  incised,  or  otherw.s7  The  di«   I 
consequent  upon  the  infliction  and  'the  healilg  „f  ^'^Li:  ^  ^n"/ 
may  be  so  slight  that  the  disPicp  ,-»  i..,*  •        T   ,  ^^^^  wound, 
But  the  .ore  odious  P-sXl  IS  T tc  r^S 
contused  wounds,-tho  inflammation,  and  the  nlceratioTll  Z 
»»ppurat.on  cause  too  n,ucl>  irritatio;  for  healthT Zar'and  turn 
the  process  ,nh,  one  of  disease.    It  will  be  remembereT  that  eve„ 
m  ordinary  inflammatinn  the.  M^  ^  ,     "^^muerea,  tnat  even 

dicated  b/inflananTat;  f     r     Whe7a"n„"°°""  ■'''"'"''  "'  '- 

it;t„Te::.-^---"^^^^^^^ 

e.el=.^r LCLtrCHoL^^^^^^^^^^  ^ ^  ^ 
whenitisthepertonelthrv     1  r"™''"-'^  i»feetious; 

peKtouitis  isdr:rr:™it;;re::srpi^^^^^^^^^ 
nxiiiVd^d^f^rr^tr-^^^^^^^^ 

entirely  subsidine  lin„^r»  :„  T  inflammation,  instead  of 

of  redness  o  Tn^  ;i       '"    ''!  7'' P-^aps  with  a  good  deal 
form  around  the  w2  wl  T  ■  """  ^  """■"  "'''"l^'  -ay 

the  disease  incrcasis  the'-         '"""T"  '"'™°''  P"""'-'     ^s 

of  tte  .bsorbr  I'nd  Vt  ndT;r: :  7e  t "°"'  T  "■"°"- 

ness  and  swelling      Th.  „!„    i    u  ™'*'^''  °''  ^^«»  lender- 

.i.edi.ch.r;:":"'';heKi\trs;ir "'  •:"'°^«^''" 

"long  the  absorbent  vessels      Thl         ,   ^  '"  ""  P""'*?' 


iiil 


m 


i!, 

1     ; 

iM 

i        *h'!   ft  pffi 

240 


PRINCIPLES    OF    SURGERY. 


has  not  been  very  virulent,  nor  great  in  quantity,  and  the  consti- 
tution of  the  individual  is  in  other  respects  healthy,  so  that  the 
powers  of  nature  were  capable  of  overcoming  the  action  of  the 
poison.  Bqt,  even  in  these  milder  cases,  time  and  judicious  treat- 
ment are  essential.     The  disease  is  chronic,  but  mild. 

When  the  disease  is  acute  the  symptoms  are  better  marked,  and 
quick  in  their  progress.  In  the  part  wounded  there  is  a  low  form, 
but  a  destructive  inflammatory  action.  It  soon  extends  up  the 
absorbent  vessels,  and  the  glands  become  much  inflamed,  and  sup- 
puration of  a  low  order  will  quickly  follow.  The  whole  limb  will 
become  cedematous.  Pain,  which  in  the  milder  form  was  but  little, 
is  of  a  dull,  but  distressing  nature.  Redness  with  a  livid  cast  is 
not  confined  to  the  track  of  the  vessels.  It  is  the  arm  which  is 
generally  aff"ected;  and  the  local  disease  continuing  to  extend, 
passes  the  shoulder  along  the  anterior  and  posterior  parts  of  the 
thorax.  Although  the  limb  is  much  swollen  and  in  places  intensely 
red,  yet  if  an  incision  be  made  the  quantity  of  fluid  to  escape  is 
very  limited.  The  blood  circulates  through  the  tissues  sluggishly 
at  the  first,  and  at  last  becomes  stagnant.  Perhaps,  in  places  the 
tissue  is  undergoing  changes  which  indicate  its  death.  When  such 
local  symptoms  as  these  present  themselves  the  case  may  be  looked 
upon  as  one  which  is  very  likely  to  prove  fatal,  notwithstanding 
all  efforts  of  nature,  aided  by  treatment. 

Constitutional  Symptoms. — In  the  milder  form  of  the  disease 
the  constitution  is  but  little  aff'ected;  but  it  is  far  otherwise  when 
the  acute  disease  attacks  a  part.  Then,  of  course,  there  are  cases 
intermediate  in  degree,  in  which  constitutional  symptoms  will  be 
more  or  less  severe.  One  of  the  first  constitutional  effects  is  a 
dulness  of  the  spirits,  a  degree  of  lassitude,  with  loss  of  appetite. 
Then  diarrhoea  will  come  on.  All  of  the  excretions  are  exceedingly 
off'ensive.  Not  only  the  breath,  but  the  exhalations  from  the  skin, 
are  strikingly  putrid.  It  has  been  observed  by  many  that  the 
off'ensive  smell  bears  a  resemblance  to  the  dead  body  from  which 
the  poison  was  derived.  In  the  comparatively  milder  cases  these 
symptoms  may  gradually  wear  away.  In  the  severe,  extreme 
prostration  will  supervene,  with  delirium,  or  coma.  The  bowels, 
sometimes,  instead  of  being  relaxed  will  be  constipated.  There  is 
commonly  in  the  worst  cases,  fever  of  a  typhoid  type,  with  occa- 
sional profuse  perspiration.    The  tongue  is  at  first  pale  and  flabby, 


POISONED    WOUNDS. 


241 


or  perhaps  coated,  with  a  tendenov  tn  h 

wh.h  completely  orushe,  „„t  .he  vkaHt/„     hXll  *''  f"™"' 

Treatment   of  Bmecting    Wounds  -tI  T  ^T 
made  "-^  a  scalpel  while  diLo^gf;"!:".":'?''^  '"'™'' 
amiuation,  but  little  attention  ia  relief  V,rf ','""'  '" 
to  thoroughly  wash  tt,o  „.,.     "J"'""-     i'  '3  only  necessary 

placing  th!  wound  to  Z  I  'anTfT  """""^  ''^^"'"^  "^ 
Although  .here  may  be  no  bleed! IveTb  """"'''  ""''»8  "- 
the  fluids  around  the  wound  .„7M' th.  '°""'"  ""  "'"""" 
which  may  be  located  in  thel!.  \  u  I™'  """"  "'<'  ?»'»"". 
net  had  Le  to  r  ya^a?  ^hl.I  '"'-"^  ^""^"'^  '«- 
that  the  system  is  afreadrimbrd "i  h  h'  "  •"""  '"  ""''"" 
poison  is  of  a  virulent  Icind"^  Z  b"  si  ps  wmT™'  "  ""™  '"^ 
it  will  be  remembered  that  1  lad?,*  ]  "^     v        "ooessary.    And 

htely  to  prove  serious  .Wnt,  ol". 'T' rr"  '^  """- 
work  of  repair  will  be  mnr„  ,        ,  '  ""'^  ''""use  the 

ci»edwound^he  wha;:i;::etr:ndt  '::r- » '"^  »■ 

hkely  .0  be  washed  out  of  the  wotnd  TK^  '  "™  '^  ""^^ 
aimed  at  is  to  tarn  .he  current  h?^.  I  «™'  "'•J"'"  '"  '»' 
ried  into  the  system  and  „s  iVfl  f  °  '"t""  ^-^  ^^  ■="" 
ingis  to  be  fafored/by  ba°.r;:h':,t:  Ha™  wX"-  if  ^^■ 

i'ts't:Te::ird!r^^^^^ 

-und,  with  the  vCof  causbfbir;'""'  T*  "  ''"'^^'  '"  *■>« 
however,  doubtful.  Whil  c er,!in  slt.T '  t  ""■"'y  °f  *-  »• 
blood  flows  therefrom  .he  vir.  1  7  T""''  ""  "P"""''  ""'' 
veiling  to  the  venouT^urren  iT -^  t™b  bl"  ^  «"'"^"^  *^»- 
»PpIy  a  ligature  tightly  a"„„nd  hi  r'^f^u  ^°""'  '"''"'■'«'  '» 
the  woundfan,!  thereby  arreTtb  '  \'''°'"  •"'•"■'"'=  ='''«™ 

may  be  .h^  vehic  e  of  fhe^Ti    ^::;T'  °'  '^""^  "»»"■  --ch 
hemorrhage.  ^       '    '"'  ""■"  """="  '"""e  degree  of 

The  cautery  has  been  highly  recommended  by  some  h„.  ,,, 
IS  some  reasonable  doubt  resnectin,,  .h-.  „       -^    !     '         "'*''<' 
When  the  constitution  is  ,   t  aCt  i  P^P^'y  "f  employing  it. 
of  nitrate  of  silver  may    bv  de^  T'""'"''  "'<"'PPli«'"io-' 

vi.™  Moposited,  ,::!;x  errLi^;:':;:,:.;" -t'^' 

7  wen.    But  when  the  const.tution  is  already  impregnated 


f    if 

'(i 


;4N 


16 


242 


PRINCIPLES    OF    SURGERY. 


r    s 


i!  III! 


with  the  poison,  the  caustic  can  be  of  no  possible  use ;  while  it  is 
sure  to  increase  the  local  inflammatory  action,  which,  we  have 
seen,  is  calculated  to  intensify  the  general  disease.  Indeed, 
nothing  should  be  applied  that  can  increase  the  morbid  action. 
Of  cauteries,  the  nitrate  of  silver  is  the  least  objectionable,  as  it 
dries  up  the  tissue,  in  a  measure,  and  the  subsequent  separation  of 
the  eschar  is  not  attended  by  the  same  amount  of  inflammation  as 
that  following  the  use  of  more  destructive  cauteries. 

Respecting  constitutional  treatment,  but  little  need  be  said.  It 
is,  in  the  main,  the  same  as  that  recommended  for  erysipelas. 
The  diarrhoea  and  sweating  are  undoubtedly  operations  of  nature, 
endeavoring  to  eliminate  the  poison.  They  should  therefore  be 
merely  controlled,  not  arrested.  As  the  faeces  ought  to  be 
promptly  removed,  so  ought  the  excretions  of  the  skin.  Washing 
and  rubbing  of  the  skin  should  not  be  neglected.  See  that  the 
patient  has  plenty  of  pure  air.  Tonics  and  stimulants  will  have 
to  form  a  portion  of  the  remedial  measures ;  indeed,  in  the  more 
severe  cases,  upon  stimulants  will  depend  the  chance  of  recovery. 
In  chronic  cases,  it  will  often  be  found  advantageous  to  have  a 
change  of  air,  scene,  and  diet. 

The  second  class  of  poisoned  wounds  are  inflicted  by  a  healthy 
living  animal.  Of  these  it  is  unnecessary  to  speak.  I  am  not 
aware  of  any  animal  at  the  present  time  in  Canada,  whose  bite  is 
particularly  dangerous ;  although  the  sting  of  some  bees  is,  for  a 
time,  very  painful. 


CHAPTER    XXXI. 

Third  Variety :  Hydrophobia— Two  Kinds— Dog-madness— Symptoms— Three 
Stages— Symptoms  in  Man— Course— Diagnosis— Pathology— Period  of  La- 
tency— Prognosis — Treatment. 

Hydrophohia. — The  third  class  of  poisoned  wounds— \hQ  only 
one  of  importance  in  this  country— is  hydrophobia;  and  the 
alarming  frequency  with  which  we  hear  of  its  occurring,  and  de- 
stroying life  in  the  most  distressing  manner,  calls  for  a  careful 
consideration  of  the  disease. 


HYDROPHOBIA. 


243 


yl  oL       Th  '  rS       ""  """--'"i-l  ty  certain  well-marked 

but  the  saliva  !,      T„  .t         ^'  •  ""*  "  ""'  '"<''f  Poi™nou8, 

rt  lie    f  p";„„     '^^f "-'«'»'  »f  'be  „,o»th  resides  the  fata 

the  absorbents.     But  any  wonnd,  it  matters  not'^ow  made  1„^ 
sore    any  abras.on;  even  a  thinness  of  the  integumlt  wi  ,'suffi 
cen  ly  open  a  channel  by  which  the  saliva  can,  ff  bTuehT  L  i!" 

::!'ZTtZ'''''''''  "J"  f -"^  "■»  poison  i:tmV,"f:; 

me  system.     Cases  are  mentioned  bv  writers   u-Jior«  +v.      r 
™  contracted  by  a  -bid  dog  licWn'g  I^frc'e,;    1 1'^;' 'ri 
sm.  1  p.mples,  or  which  had  been  cut  by  a  razor 

JTT-\~'^T  '"'"'''  "'  M'-ophoWa  are  men'tioned  by  writers 

ST.  :Kt  ^.Ti  ';:-:.r  "•■  -'•-  •"•"■•- 

On^>n.-Hydrophobia  is  supposed  to  arise  spontaneously  in  the 

f  ti:  brdrr'^v  ■"  *^'  ""^  r  *^  <■«-  *«  -f.  *e  >  ui 

ratlfof  t  f  Isea!    rpVcWWi  T  T"  '''T''  '^  ""  S-- 
.he  extremes  of  Jt  IT^'/Z^H  if  Tnll  '"d""^' 

likely  to  have  something  to  do  with  it      TTn^n+iofi  a  ^^/"o^e 

is  also  supposed  to  be  provocate    o    the  ;rB„:rf  t" 
the  origin  of  the  disease  is  not  understood  "' 

Dog-madness. — Inasmuch  no  I'f  ;a  +u    j      .i 
5^  disease  to  man,  it  is  nt  sly  ,:  Z^l^l^^SZ 

H~c;:H?er  ■"  "■"'  ^■""■^•'  -^  '-^  Atomst;:;ict 

same-'vertWd"  "  ""/°«'  ""^  '^'"P'™^  "^  »»'  "'"Js  the 

r     One  of  th'rr    ""^^  «°"  °"  '°  "  »"'^'^  '•■"a'  '-mina! 
One  of  the  first  symptoms,  in  the  dog,  is  a  decree  of  rest- 


( 


i»i 


:iit 


\  ■ 


\&n 


244 


PRINCIPLES    OF    SURGERY. 


lessness,  and  suspicion  of  every  body  and  thing;  even  his  own 
master  will  be  regarded  with  a  perceptible  degree  of  fear.  In- 
stead of  going  as  usual  to  his  kennel,  he  seeks  unusual  places  in 
which  to  lie.  As  the  disease  becomes  developed,  he  will  at  times 
snap  in  the  air,  as  if  at  flies.  The  eye  becomes  unnaturally  bright 
and  sparkling,  so  much  as  to  seem  reddish.  It  is  not  bloodshot ; 
but  rather  like  that  of  a  wild  savage  animal  in  the  shades  of 
night.  The  mouth  and  throat  soon  become  affected,  the  secretions 
of  the  mucous  membrane  thereof  being  abnormal — thick  and  te- 
nacious. The  efforts  to  dislodge  this  give  rise  to  an  unnatural 
barking. 

The  following  is  taken  from  the  System  of  Surgery,  and  is  de- 
rived from  the  writings  of  Virchow.  He  describes  the  disease 
in  dogs  as  consisting  of  three  stages,  and  in  the  following  manner: 
"  The  first  stage  is  the  melancholic,  and  is  often  unnoticed  and  un- 
recognized at  itc  onset ;  still,  there  may  be  observed  a  palpable 
change  in  the  natural  condition ;  alternations  of  depression  and 
exaltation;  restlessness,  and  change  of  place;  sudden  waking 
from  sleep ;  irritability  ;  deranged  digestion ;  anorSxia.  The  dog 
has  often  a  greedy  appetite,  but  sometimes  leaves  his  food,  or 
snaps  at  it.  There  is  natural  thirst,  and  no  fear  of  water.  After 
these  premonitory  symptoms  have  set  in,  the  specific  character 
soon  becomes  developed.  There  is  great  susceptibility  in  the  cica- 
trix, when  a  bite  or  wound  has  been  the  antecedent ;  a  change  of 
affection,  character,  and  desires;  a  proneness  to  lap  his  own 
urine,  and  eat  the  fiieces  of  other  dogs ;  a  peculiar  idiosyncrasy  to 
take  all  sorts  of  unwholesome  and  indigestible  things,  such  as 
straw,  paper,  wood,  &c.  There  is  much  sexual  excitement,  and 
eager  licking  of  the  genitals  of  other  dogs.  He  seems  friendly 
with  the  cat,  but  exhibits  a  marked  change  of  affection  toward  his 
master.  He  becomes  shy  and  backward,  and  avoids  observation. 
The  organs  of  deglutition  and  respiration  become  involved.  There 
are  spasms,  and  difficulty  in  swallowing,  as  if  something  was  stick- 
ing in  the  throat ;  alteration  in  the  voice ;  arrest  of  salivary  se- 
cretion ;  application  of  the  tongue  to  cold  surfaces,  such  as  stone, 
iron,  iic.  Changes  also  take  place  in  the  motor  system,  for  in  all 
there  is  more  or  less  debility  and  weakness. 

*'  The  second  stage  is  the  irritable  and  furiom.  It  commences 
generally  in  from  one  to  three  days,  but  may  set  in  after  twelve 


)'!» 


HYDROPHOBIA. 


245 


hours;  it  is  seldom,  however,  met  with  after  the  eighth  day 

Its  course     The  paroxysms  are  strongest  and  longest  at  the  onset 
commencmg  with  restlessness  and  irritability.    He  run   ou  of  the 
house,  attempts  to  bite,  goes  from  place  to  place  wiZut  thou^t 

:^n  "^^^^^^^^^^^  'iTtLr  '^''^  ^"''  \'' '-'-  '-'-^ 

J      .f         ■  ,'"""""•     "  "8  this  proneness  to  b  to  which  rm 
aers  this  period  so  dsni»>rnii<:      Ti,« 

hours  and  ofL  """S*""'-  The  paroxysms  may  last  several 
hours,  and  often  even  a  whole  day.  Then  follows  a  remission 
wh,oh  „  very  deeeptive,  as  all  signs  of  disturbance  subside  b„^ 
the  dog,  aware  of  hi,  unsociability,  generally  hides.  The  dilease 
.s  often  described  from  dogs  who  have  been  hunted,  hooted  and 
followed  about  m  the  street,  and  goaded  on  ,„  mad;ess  and  "n 
these  severe  symptoms  are  superadded,  such  as  panting  Ind  flow 

. tust:^fT:'f  b^t  °'  \""'^''  *i-.,'dread''of tat: 
th  ust  „g  of  the  tai    between  the  legs,  starting  of  the  hair,  &c 

The   h,ef  and  prominent  symptoms  of  this  stage  consist  in  psy 

hieal  and  esthetic  changes;  there  is  a  kind  of'acute  man  a 'aifd 

del.  mm,  disobedience,  no  knowledge  of  his  master,  no  avoidance 

of  danger,  sudden  anger  and  snappishness,  outbursts  of  wildness 

loss  of  general  sensation  and  all  sexual  feeling.     The  chanr'n 

bXTn;;    '^""^T  •""■■  '"'™''  '™"  °f  voice    betwen 
barking  and  howlmg,  indicative  of  extreme  distress;  spelling  of 

e  fauces,  tongue,  and  nose.     The  movement,  of  the  body  arc 

ash  and  hasty,  and  the  hearf,  impulse  strong.     The  durationTf 

.his  s  age  varies.     It  generally  lasts  three  o'r  four  %,  Cin" 
ni»  the  next  and  final  stage;  but  ™  rare  instance,  it  m/Z' 

nate  suddenly  in  death,  through  a  form  of  apoplexy.  ^ 

wenke  V„,r  "T  "  ""7'"-'"^"'"-    The  paroxysm,  now  become 
weaker  iind  remittent;  the  animal  emaciates  rapidiv  the  coat 

mc    he  1  es  on  one  side  in  great  prostration,  but  when  rouseil  is 
W  Isnappish,  and  bite,;  if  able  to  walk,  he  totters  and    lag 
™      a  ong;  t  e  eye,  are  sunken  and  dull,  the  mouth  open  am 
Iry      e  tongue  hanging  out  and  hard,  the  heart',  action  weak 

«^  r  irTfr"'',*"  '""""■«  "'"--'•  ^  ^-u,,™; 

r™  ?„  f       T     "'""  '''"'="  '■'•'""  "''»"»««">  or  during  a  par- 
oxysm,  in  from  five  tn  e  "ht  <1"""  '— i-    •      -  ^     I '" 


iU  - 


wic  nrsi  ttitiick. 


This 


i'     ! 


a  kinu 


■a 


■  !     t 


11  :w 


;  ■'■!?'?  fill 


,'i ; 


m 


'  'h? 


'U 


B. 


\?i 


'  1 1 


246 


PRINCIPLES    OF    SURGERY. 


description  is  so  important  and  truthful,  that  it  could  not  be 
abridged. 

Frothing,  to  which  so  much  importance  is  commonly  attached, 
is  due  to  the  efforts  to  dislodge  the  tenacious  mucus  in  the  throat. 

Symptoms  in  Man. — We  have  now  to  notice  the  symptoms  of 
the  disease  in  man.  They  are  local,  and  general  or  constitutional. 
The  wound  in  most  cases  will  have  healed,  perhaps  been  healed  for 
weeks,  when  the  first  uncertain  constitutional  symptoms  begin  to 
appear.  But  now,  as  a  general  thing,  the  part  which  had  been 
wounded  takes  on  inflammatory  action ;  and  if  the  wound  has  not 
healed,  it  assumes  .the  appearance  of  an  inflamed  ulcer.  There  is 
redness  and  pain,  which  gradually  extend  toward  the  body  along 
the  ("ourse  of  the  nerves.  In  the  part  will  sometimes  form  a  vesi- 
cle, in  which  will  be  collected  a  drop  of  serum-like  substance.  At 
the  same  time,  a  group  of  similar  vesicles  will  sometimes  form 
under  the  tongue,  by  the  foramen.  The  fluid  in  these  is  said  to  be 
highly  poisonous.  An  Italian  physician  entertained  the  idea  that 
if  these  were  duly  opened,  the  disease  would  be  aborted ;  but  fre- 
quent experiments  have  proven  the  fallacy  of  his  supposition. 
Nevertheless,  it  is  recommended  to  carefully  puncture  these,  and 
remove  the  concained  fluid. 

The  constitutional  symptoms  are  very  slow  in  their  development. 
In  most  cases,  the  patient,  for  an  indefinite  time,  feels  an  indefina- 
ble indisposition — a  dread  of  impending  danger.  If  he  be  aware 
of  the  nature  of  the  wound  which  he  had  received,  he  will  be  un- 
willing to  entertain  the  thought  of  hydrophobia,  yet  it  will  force 
itself  upon  him.  The  mind  very  often  becomes  unusually  active ; 
the  conversation  will  be  brilliant  and  witty ;  the  imagination  vivid 
and  flighty.  Sometimes,  on  the  contrary,  he  is  melancholy  and 
dejected.  This  state  of  mind,  and  these  uncertain  symptoms,  may 
continue  for  several  days ;  after  which,  the  more  characteristic 
symptoms  begin  to  appear.  Among  the  first  signs  will  be  those 
arising  from  embarrassment  of  the  respiratory  organs ;  at  the 
same  time  the  glands  of  the  mucous  nienibrane  will  pour  out  a 
secretion  more  copious  and  viscid  than  natural,  which,  adhering 
tenaciously  to  the  surface,  urges  the  patient  to  make  extra  cftorts 
to  expel  it.  These  efforts  are  attended,  in  many  cafecs,  with  an 
unnatural  hawking  noise.  It  is  this  which  imagination  has  likened 
to  the  bark  of  a  dog,  and  it  has  been  supposed  to  be  an  attempt  on 


HYDROPHOBIA. 


247 


thepart  of  the  patient,  while  u„dcr  the  influence  of  the  disease 
to  imitate  the  dog  which  had  bitten  him. 

The  paroxysms  increase  in  frequency  and  severity,  durine  each 
of  which  the  mouth  opens  and  shuts  convulsively,  which  g"ves  the 
p.  len,  the  appearance  of  one  snapping  at  objects.  BuTth  s  i 
not  as  has  been  supposed,  an  effort  on  the  part  of  the  subject  to 
grati  y  a  rabid  desire  to  bite.  It  is  only  the  uncontrollable'action 
of  the  muse  es  about  the  face  and  throat.  Between  the  paroxysms 
the  patient  ,s  fully  sensible  of  his  condition;  indeed,  Z^Zl 
the  fit  IS  on,  he  IS  quite  aware  of  his  state,  but  is  impati;'t  to 
resist  the  irregular  action  of  the  muscles.     When  the  period  of 

note  of  fte  ?"'/,"  \'- '""""''  "^  "■»  '"«»•  ''^  -ill  often  give 
notce  of  the  fact  to  his  attendants.     But  the  attack  may  be 

bought  on  suddenly,  by  any  sudden  alarm;  and  he  is  easily 
startled  by  an  unusual  sound  or  motion.  At  such  times  he  wiU 
assume  the  attitude  of  defence,  or  as  if  about  to  deal  a  blow  to 
some  supposed  foe.  It  is  characteristic  of  this  disease,  in  all  .2 
mas,  to  make  use  when  alarmed,  of  the  natural  weapon  of  pro- 
tection to  the  body:  thus,  the  dog  will  bite,  the  cat  will  scratch 
and  me,  the  ox  wil  use  his  horns,  and  man  will  use  his  fists. 

The  word  hydrophobia  indicates  a  fear  of  water ;  and  the  popu- 

l«r  belief  ,s,  that  any  animal  suffering  from  this  disease  will  neces- 

sarily  have  this,  as  the  most  prominent  symptom.    But  the  fact  is, 

fear  of  water,  or  any  other  fluid,  is  not  alway>  present;  and  when 

her   IS  a  dread  of  water,  it  arises  from  the  insufferable  pain  which 

as  been  occasioned  by  efforts  to  swallow  it.    As  the  disease  is 

oveloped,  the  tough,  tenacious  mucus,  and  the  irregular  action  of 

imcTe  ,?  T-7  "-".^""""-S  »f  «-->".  whilf  at  the  same 

he  wished-for  fluid  cannot  bo  swallowed,  that  causes  the  patient 
to  shun  the  appearance  of  water,  or  any  other  fluid.     E,™  the 
»onnd  of  water  often  produces  feelings  of  great  distress.     Some- 
.....cs  the  mentioning  of  it  will  beget  feeling,  of  extreme  terror- 
and  also  he  sight  of  tears.    But  the  patient  will,  for  a  long   iW 
.uc„e.,sfully  try  to  swallow  fluid, ;  and  when  it  become,  distrtssi:;,' 
I    w  11,  a.  If  anxious  to  silow  he  has  not  the  ,li,™,e.  u.e  the  mof 
tormined  effort,  to  swallow  .Iraugh.s  of  water.     Sometimes,  in 
e,g  ,  of  the  ,li,e^e,  the  thirst  will  be  so  great  that  the  p„- 
litnt  will,  with  heroic  determination,  carry  a  cup  to  hi,  lipn,  and 


...Jf 


A- 


ii 


I  * 


m 


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>  i^:' 


\   V 


'' » 


1-] 


248 


PRINCIPLES    OF    SURGERY. 


even  succeed  in  gulping  down  large  draughts  of  water.  At  first 
he  may  be  unsuccessful,  the  cup  being  involuntarily  drawn  away ; 
but  after  repeated  efforts,  the  fluid  will  be  swallowed,  although 
mortal  terror  is  in  his  countenance. 

There  will  be,  from  first  to  last,  occasional  periods  of  fever  and 
headache.  There  is  often  a  pain  shooting  from  the  wounded  part 
through  the  body,  like  that  of  rheumatism,  and  centring  in  the 
region  of  the  heart.  The  penis  is  often  in  a  state  of  erection,  and 
there  may  be  priapism,  and  seminal  ejections.  Vomiting  is  a  com- 
mon symptom,  and  entire  loss  of  appetite ;  but  sometimes  the  pa- 
tient will  be  able  to  take  food.  Restless  and  easily  excited  at 
first,  he  becomes,  toward  the  last,  entirely  wakeful,  as  if  in  utter 
despair,  and  is  often  exceedingly  rageful.  The  urine  is  passed 
with  frequency,  and  at  last  involuntarily.  As  the  disease  ap- 
proaches toward  the  paralytic  stage,  all  of  the  symptoms  are 
intensified,  until, — the  strength  of  the  patient  being  exhausted 
from  the  unnatural  excitement,  the  terror,  and  the  want  of  nou- 
rishment and  drink, — depression,  delirium,  and  paralysis  super- 
vene. "  The  pulse  becomes  small,  quick,  and  irregular ;  the  skin 
bedewed  with  clammy  sweat ;  the  eyes  dull  and  sunken,  and  the 
pupils  large ;  and  death  takes  place,  either  from  asphyxia  during 
one  of  the  convulsive  attacks,  or  from  exhaustion.  The  patient, 
however,  may  die  quietly,  sinking  into  a  state  of  repose,  with 
abatement  of  all  the  symptoms ;  in  one  case  being  able  to  eat 
and  drink,  and  expiring  immediately  on  suddenly  waking."  (Sys- 
tem of  Surgery.) 

Its  Course, — The  disease  will  generally  run  its  course  in  two  or 
three  days ;  it  may,  however,  extend  over  a  week,  or  eight  days. 
As  intimated  above,  the  patient  will  generally  die  from  exhaustion, 
and  the  duration  of  the  disease  will  depend  upon  the  powers  of 
the  patient  to  withstand  the  depressing  effects  of  the  disease. 
Sometimes  death  is  hastened  by  some  complication,  as  the  arrest 
of  the  function  of  the  lungs  by  congestion  or  paralysis.  Occa- 
sionally, apoplexy  suddenly  closes  the  dreadful  scene. 

No  two  cases,  probably,  will  be  found  to  possess  just  the  same 
features;  but  the  disease  may  with  propriety  be  divided  into  three 
Stages.  The  first  of  which  has  the  premonitory  symptoms;  the 
second  is  characterized  by  irritation  and  rage;  the  third  by  a  ten- 
dency to  paralysis.     (System  of  Surgery.) 


HTDKOPHOBIA. 


349 


Z)M^n«,._The  only  diseaseB  with  which  hydrophobia  may 
po  s.bly  be  confounded  are  te.an„,  and  hysteria.  To  distinguish 
n  from  tetanus  .t  ,s  only  necessary  to  notice  the  character  i  the 
spasms  In  hydrophobia  they  come  on  in  paroxysms,  while  in 
tetanus  the  contraction  of  the  muscles  is  consLt.  Instead  of  the 
irregular  action  about  the  throat,  there  is  continued  lockjaw. 

Hydrophobia  ,8  sometimes  simulated  in  hysteria.  Fear  of  water 
.s  commonly  supposed  to  be  the  characteristic  symptom  of  the 
d-sease,  consequently  the  hysterical  patient  has  this  as  the  chief 

or„rb  /  f  J'"'  °'  ™'"  ''  "='y  «-"•  "»  tte  other  symp- 

m   of  hydrophobia  are  absent.     The  history  of  the  case,  as  weU 

as  he  various  circumstances  existing  in  connection  with  it  will  be 

phTbia       "  ^  ^^°'"'  "  '™  ^""'  "  'P"™"'  ~«^  "f  hydro! 

Pathologi,.-The  manner  in  which  the  system,  some  time  after  the 
bite,  becomes  aifccted,  and  the  disease  is  established,  is  a  question 
concerning  winch  much  has  been  written,  and  with  regard  to  which 
here  seems  yet  to  be  some  difference  of  opinion.    The  poison  is  in- 
re  uced  into  a  part  of  the  body.     Attending  the  wound  there  is 
no  ymptom  nor  other  indication  of  its  deadly  nature.    The  imme! 
latc  -u'ts  of  the    ite  of  a  mad  dog  are  in  no  way  differentrm 
h  se  inflicted  by  a  dog  not  mad.    The  usual  course  is  pursued  by 
nature  to  heal  the  wound ;  restoration  is,  in  most  cases,  as  quickly 
and  perfectly  effected  as  in  a  wound  not  thus  poisoned.    Cicatriza^ 
.on  1,  complete,  the  function  of  the  part  is  in  all  respects  per- 
fectly  restored.    After  an  indefinite,  but  generally  prolonged 

*rt  'b        TT"  f  "'■'"''  ■'  '"'^  ''^y^'  "■"  00-titutiofai 
effect   begm  to  show  themselves;  then,  and  not  till  then,  the  part 

wounded  also  manifests  certain  peculiar  symptoms.    What  are  the 

stops  between  the  cause  »n,l  the  effect,  which  are  so  silently  taken  ' 

I»  It  possible  to  trace  the  chain  of  morbid  links  which  stretches 

over  the  interim  of  silence?    Is  the  poison  taken  „p  b^  the  al 

Jbents;  does  it  pass  directly  into  the  blood;  and  there, In  course 

of  tunc  become  developed,  as  for  instance  in  small-pox!    Or  Zs 

.t  act  from  the  first  upon  the  nervous  system  ?    Some  pathologists 

hoi  I  one  view  some  the  other.     The  local  and  genera    sympfoms 

quo" liofs'  "'  '"  ""•"■'  "'  P"''"'"  '•««''"«  »«  ">e  above 


Hi 

inf  ? 

'               H    ^ 

^ji 

■MS 

A.   • 

'■  \ 

I'ii 

i-'i 

km 

'  ,1 

5    'I 


u 


w 


il  '. 


Mi 


\i 


m 


m 


4 


m 


i       in^ 


250 


PRINCIPLES    OP    SURGERY. 


This  disease  diflfers  very  much  from  small-pox,  and  kindred  dis- 
eases, in  this  respect,  in  that  the  period  of  latency  is  prolonged, 
and  is  unattended  with  any  symptom  whatever.  This  has  led  to 
the  supposition  by  some,  that  a  double  zymosis  takes  place;  first 
in  the  part  wounded,  by  which  the  poison  is  increased  or  intensi- 
fied so  as  to  cause  it  to  be  taken  into  the  system,  and  then  having 
gained  admittance  into  the  blood,  a  second  development  follows, 
by  which  in  due  time,  the  whole  volume  of  blood  becomes  afi"ected. 
Probably,  however,  the  other  theory,  that  the  virus  acts  solely 
upon  the  nerves,  will  prove  to  be  the  most  in  accordance  with  the 
nature  of  the  symptoms. 

The  virus  is  received  into  a  part  of  the  body.  Its  eff'ects  are 
directly  upon  the  nerves  therein.  Probably  not  creating,  as 
Chelius  supposed,  a  kind  of  quick  running  inflammation,  but  a  dis- 
turbance somewhat  analogous  to  it.  In  course  of  time,  the  length 
of  which  will  depend,  first  upon  the  extent  to  which  the  poison  is 
brought  in  contact  with  the  nerve-tissue,  or  the  intensity  of  the 
poison,  and  secondly,  upon  the  strength  of  the  constitution,  and 
other  circumstances,  the  disease  of  the  nerves  insidiously  creeps 
along  the  nerve-trunk  to  the  nerve-centres,  and  finally  culminates 
in  the  spinal  centre,  or  the  medulla  oblongata ;  and  still  working 
out  its  poisonous  effects,  causes  abnormal  reflex  action  in  certain 
nerves,  those  especially  about  the  throat;  and  hence  the  charac- 
teristic symptoms  of  the  malady.  From  post-mortem  examinations 
it  is  known  that  the  medulla  oblongata  is  principally  affected.  It 
is  generally  found  softened.  This  softening  sometimes  extends  to 
the  striated  bodies.  The  nerves  which  are  most  affected  are  the 
eighth  pair,  and  it  would  seem  that  it  is  the  morbid  communica- 
tion  sent  by  these  nerves,  which  produces  all  of  the  characteristic 
symptoms  of  the  disease,  such  as  the  morbid  condition  of  the  mu- 
cous membrane  of  the  mouth  and  throat,  the  abnormal  secretion 
of  the  glands  thereof,  the  unnatural  condition  of  the  tonsils;  also 
the  spasmodic  action  of  the  pharynx,  the  trouble  in  breathing, 
and  the  frequent  paralysis  of  the  lungs,  the  derangement  of  the 
stomach,  &c. 

There  is  great  congestion  of  the  encephalon,  as  might  be  ex- 
pected from  the  terrific  spasms  of  the  disease.  The  blood  is  said 
to  be  more  fluid  than  in  health ;   the  red  corpuscles  are  broken 


HYDROPHOBIA. 


251 


effects  are 
•eating,  as 
1,  but  a  dis- 
the  length 
e  poison  is 
sity  of  the 
tution,  and 
isly  creeps 
culminates 
11  working 
in  certain 
he  charac- 
aminations 
Fected.  It 
extends  to 
ed  are  the 
onimunica- 
iracteristic 
of  the  mu- 
,1  secretion 
nsils;  also 
breathing, 
ent  of  the 

gilt  be  ex- 
ood  is  said 
ire  broken 


down,  and  the  tissues  are  infiltrated   by  the  unnaturally  dark 
coloring  matter.  j   "^la. 

Although  much  uncertainty  exists  as  to  the  origin  and  mode  of 
development  of  the  disease,  it  is  well  known  that  it  is  propagated 
by  inoculation  through  the  agency  of  the  saliva  alone  ''From 
experiments,  it  is  proved  that  neither  the  blood,  flesh,  milk,  seminal 
fluid,  nor  the  breath,  nor  the  secretions  and  excretions  of  the  ab- 
dominal viscera,  are  capable  of  producing  hydrophobia,  although 
Mag  ndie  has  endeavored  to  prove  that  the  blood  is  contagious  " 
(System  of  Surgery.)  ^ 

Through  the  agency  of  saliva  the  disorder  may  be  communi- 
cated by  those  animals  before  mentioned,  among  themselves,  and 
herbivorous  animals,  to  fowls,  and  to  man.  But  the  disease  can- 
not be  communicated  at  all  by  herhivoroua  animals,  and  there  is 
no  case  on  record  where  the  disease  was  communicated  by  one 
human  being  to  another.  There  is,  however,  a  case  recorded  by 
Magendie,  m  which  it  was  communicated  to  a  dog  by  saliva  taken 
from  a  man  just  before  his  death  from  this  disease.  This  dog  bit 
another,  and  both  of  them  died. 

With  regard  to  the  period  of  latency,  it  has  been  stated  that  the 
average  time  IS  about  forty  days.     But  a  few  cases  are  recorded, 
in  which  the  disease  was  developed  in  a  much  shorter  time,  while 
on  the  contrary,  some  cases  are  mentioned  where  the  period  ex- 
tended over  years.     The  case  of  the  Duke  of  Richmond  is  sadly 
mteresting,  because  of  the  fact  that  he  was  far  away  from  home, 
ma  half  settled  colony,  and  because  that  colony  was  Canada 
H.8  death  occurred  in  1819,  and  the  disease  "was  attributed  by 
his  Gi-ace  to  having  had  a  cut  on  his  chin,  made  in  shaving,  licked 
by  a  dog  five  years  previous  to  the  appearance  of  the  disease. 
But  It  IS  much  more  probable  that  he  was  infected  by  a  tame  fox 
which  bit  him  through  the  thumb  six  or  seven  weeks  prior  to  his 
death.       (J.  F.  South,  Chelius'  Syst.  Surgery.)     And,  with  re- 
pect  to  all  similar  cases,  there  is  a  reasonable  doubt  whether 
there  had  been  so  long  a  period  of  latency.     This  question  is  one 
0  some  importance;  for  if  the  surgeon  could  assure  one,  who  had 
be  en  bitten  by  a  rabid  animal,  that  having  passed  a  certain  time 
without  any  signs  of  the  disease,  he  was  henceforth  in  no  danger 
It  would  be  a  great  relief  to  him.    And  the  fact,  that  we  have  not 


) 


''  WM\ 


«"'?™ 


k 


252 


PRI>JCIPLES    OF    SURGERY. 


as  yet,  any  very  well  authenticated  cases,  should  warrant  the  sur- 
geon to  offer  much  comfort  to  the  anxious  bitten  one. 

Still  more,  there  seems  to  be  no  doubt  that  now  and  then,  an 
active  imagination  in  connection  with  an  exceedingly  nervous  per- 
son, may  give  rise  to  many  of  the  symptoms  of  hydrophobia,  and 
even  lead  to  death,  even  when  the  dog  which  had  bitten  the  person 
was  not  rabid. 

These  facts  make  it  desirable  that  all  reasonable  grounds  should 
be  occupied  to  relieve  the  harassed  object  of  a  suspicious  bite. 

Prognosis. — The  above-mentioned  facts  will  receive  their  due 
consideration.  It  is  an  important  fact,  and  one  which  ought  to 
afford  considerable  comfort  to  the  patient,  that  all  of  those  bitten 
by  rabid  dogs,  are  not  seized  with  hydrophobia.  On  an  average 
only  one  in  twenty  go  mad;  and,  when  the  anxious  question  is  put 
to  the  surgeon,  he  may  reply,  that  he  stands  a  chance  of  twenty  to 
one  of  not  contracting  the  malady.  Again,  when  two  or  more  are 
bitten,  the  one  first  bitten  is  far  more  likely  to  become  infected 
than  those  subsequently  bitten.  The  saliva  which  is  adhering  to 
the  mouth  will  be,  to  a  great  extent,  wiped  away  in  the  first  act 
of  biting,  so  that  when  the  next  is  seized,  although  perhaps  more 
seriously  wounded,  there  will  not  be  present  any  quantity  of  poi- 
soned saliva  to  enter  the  wound.  And  again,  when  the  wound  is 
not  attended  with  much  bleeding  the  danger  is  increased,  as  the 
blood  when  it  flows  from  the  wound,  may  wash  away  the  fatal 
virus.  For  the  same  reason,  a  small  wound,  which  naturally  has 
limited  hemorrhage,  is  more  dangerous  than  a  larger  one,  other 
things  being  equal.  Bites  upon  the  hand,  or  '"  .or  other  un- 
protected parts  of  the  body,  are  ~nore  to  be  leared  than  those 
which  have  been  made  through  a  garment.  When  the  tooth  has 
passed  through  a  thick,  dense  material,  as  the  leather  of  a  boot, 
there  is  very  little  cause  to  fear  any  evil ;  for  the  tooth  would  be 
completely  cleansed  of  the  saliva  ere  it  reached  the  skin.  All 
these  points  will  be  duly  estimated  by  the  surgeon,  before  he  offers 
an  opinion  as  to  the  prognosis.  The  most  hopeful  opinion  should 
be  expressed,  and  the  ground  upon  which  this  opinion  is  based. 

When  the  constitutional  symptoms  present  themselves,  the  prog- 
nosis in  most  gloomy.  A  few  cases  are  mentioned  in  which  reco- 
very, it  is  asserted,  took  place  after  characteristic  symptoms  had 
shown  themselves ;  but  it  is  to  be  feared  that  In  these  cases  the  ima- 


HYDROPHOBIA. 


253 


gination  had  created  the  symptoms.     What  supports  this  uncom- 
fortable  view  is  the  fsiot  thai-  ;«  „ii  iu    •  "utum- 

a  subseouenT  tZV  fj        '  ^  ■-stances  of  reputed  cures, 

a  subseqneni  trial  of  the  same  remedies  has  entirely  failed 

uZZ^'^rl^'  ""T  '"'~^'  '"""-"-^  '»  ^^teates. 
hurry    for,  of  all  cries,  there  is  none  more  alarming  and  electric 

than  that  a  person  has  been  bitten  by  a  mad  dog.    He  must  need 

accede  to  the  most  urgent  of  requirements.    To  him  will  be  turned 

many  an  anxious  face.    And  the  patient  should  be  seen  as  soon  as 

possible,  in  order  to  take  the  necessary  steps  to  prevent  if  nossT 

rests  of  others,  the  surgeon  ought  to  give  the  first  attention  to  the 
animal  supposed  to  be  rabid.    As  we  shall  see,  it  is  important  to 
know  whether  the  dog  was  actually  mad.     Inoiiries  ou^ht  to  he 
made ;  and  if  the  dog  has  not  been  already  des't  "  d  care  should 
be  taken  to  preserve  him  alive,  to  see  if  if  be  reai^;  Vd"  tli 
This  can  be  done  in  a  judicious  manner,  without  othei'  incurring 
any  risk.    Dogs  are  frequently  supposed  to  be  mad  when  tl  ^  "! 
not.    Any  sickness  or  indisposition  is  likely  to  be  regarded  by 
the  apprehensive  public,  as  that  of  hydrophobia;  and  no  do„M 
many  a  poor  cur  ,s  hunted,  chased,  and  stoned,  until  he  seems  to 
be  ,ke  one  mad;  indeed,  he  becomes  mad  in  a  certain  sefs     and 
It    fro  hing  mouth,  will  in  self-defence  attempt  to  bite  a  y'thing 
hat  obstructs  his  path.     The  surgeon' ought  first  to  determC  ff 
he  can,  that  the  dog  was  really  mad.     The  history  o     ^e  cle 
my  reveal  the  existence  of  doubt  as  to  the  nature  of  the  dLase 

-  ;s  friends,  ^^z  ;:i^;:zT::z:^^z 

horrible  suspense.     If  the  person  bitten  be  subject  to  nervoTs  im 
pression,  we  have  seen  that  imagination,  although  it  cannot  boRe 

to  death.    Still  more,  there  are  not  wanting  those  who  believe  the 
d««.sc  to  be  a  disease  entirely  resulting  from  a  busy  imag  nation 
Ccrtamly,  there  can  be  but  little  douut  that  it  will  at  leaft  aM  in 

o't  olw  in  T  -'i  ™"  1 '''''  ''''''  "  ™"  '"  coneld,   ha" 
tien.  tl  e  >       TT.  "^  ""=  P"'"'"'  ""'  <■»■■  ""-■  ''»«fi'  of  th 
dd  h         ^^  *°'"1'"'™  -  fi--''  oonsideration,  and  that  its  life 

required  than  a  sight  of  the  living  dog  after  several  days. 


I      U 


h:    I'.  J 


.: 


:'li 


li 


254 


PRINCIPLES    OP    SURGERY. 


^ 


And  should  the  dog  unfortunately  die,  it  will  be  no  worse  for  the 
patient.  But  even  then,  all  hope  is  not  destroyed ;  many  a  dog 
dies  with  the  symptoms  of  hydrophobia,  due  to  other  causes. 
Considering  the  very  great  influence  the  mind  has  upon  the  devel- 
opment, if  not  of  the  disease,  at  least  certain  symptoms  of  it,  I 
have  ventured,  in  the  class-room,  to  suggest  that  if  a  dog  like  the 
one  which  had  bitten  the  patient  were  shown  to  him,  leading  him 
to  believe  it  the  one  by  which  he  had  been  bitten,  the  disease 
might  be  averted.  The  terrible  nature  of  the  malady  might  jus- 
tify the  deception. 

With  respect  to  the  patient,  the  great  aim  of  the  surgeon  is  to 
remove  the  virus  from  the  wound  before  it  can  take  effect  upon  the 
tissue  or  be  absorbed.  Those  points  referred  to  under  prognosis 
will  receive  a  quick  but  definite  consideration,  so  as  to  estimate 
the  probable  degree  of  danger.  Flowing  blood  tends  to  carry  the 
poison  out  of  the  wound ;  bleeding  should  therefore  be  promoted. 
By  sucking  the  wound,  which  can  be  done  with  impunity  if  the 
lips  and  mouth  are  unabraded,  it  is  possible  to  draw' out  fluid  con- 
taining the  virus.  A  friend  will  generally  be  found  to  perform 
this  important  duty.  When  some  time  has  elapsed  since  the  re- 
ception of  the  bite,  this  mode  of  using  suction  will  hardly  sufiice. 
The  various  measures  recommended  to  prevent  the  entrance  of 
poison  in  dissecting  wounds,  may  likewise  be  adopted.  But  exci- 
sion of  the  tissue  around  the  wound  is  the  most  reliable  step  to  be 
taken. 

The  virus  is  probably  confined  to  the  superficial  part  of  the 
wound.  The  tooth  of  the  dog,  as  it  pierces  the  tissue,  will  be 
effectually  cleansed  of  the  saliva  as  it  passes  through  the  skin; 
and  as  the  blood  begins  immediately  to  flow  (and  if  it  continue  to 
flow),  the  poison  cannot  have  found  its  way  to  the  deeper  part  of 
the  wound.  Under  such  circumstances,  the  excision  of  the  super- 
ficial part  of  the  wound  may  effectually  remove  the  poison.  To 
insure  a  complete  removal  of  the  tissue  all  around  the  wound,  it 
has  been  recommended  to  make  a  ring  around  it,  by  the  applica- 
tion of  nitrate  of  silver,  before  commencing  the  incision.  It  is 
better  to  remove  too  much  than  too  little  of  the  tissue  which  may 
be  contaminated.  Even  when  the  wound  is  upon  the  face,  the 
question  of  deformity — of  unseemly  scars — will  hardly  be  taken 
into  consideration.     It  is  a  question,  not  only  of  life  and  death, 


HYDROPHOBIA. 


2SS 


but  Of  a  most  homble  death.  The  dog  being  really  mad,  the  face 
hav»g  been  unprotected,  the  saliva  of  the  ani™a/was  freely  be. 
smeared  upon  the  face  and  the  wound.     The  ehances,  then^  are 

P  7"  J^'';  f»"«  having  been  well  cleaned,  the  tissue  around 
must  be  effectually  e«Ued :  no  matter  if  the  ^ound  be  extensive 

lulillted  it  ^f  t  I  "'''  "'  "  *°«'"''  "  ="  f""'  has  been  much 
mflated,  It  w,ll  be  safer  to  amputate  the  member  at  once.  Some- 
tames  the  cautery  ,s  used,  both  actual  and  potential.  The  safer 
course  .s  to  exc.se,  and  then  use  the  nitrate  of  silver  freely  It  I 
even  reeommended  to  excise  the  cicatrix  after  the  constftul -old 
symptoms  have  begun  to  appear.  Respecting  the  propriety  of 
such  procedure,  there  is,  however,  some  reasonable  doubt 

Oo«mtut,onal  Treatment.-T>unns  the  period  of  suspected  la- 
te  ey,  constant  efforts  should  be  made  to  tranquillize  the  mind  by 
rehevmg  ,t  of  unnecessary  apprehension.     Unfortunately,  when 
genera   symptoms  have  shown  themselves,  but  little  can  b    done 
To  palhate  ,s  the  highest  aim  the  surgeon  can  take.    It  is  s  ar  ely 
necessary  to  enumerate  the  long  list  of  antispasmodics  and  seda! 
t.ve»  wh,ch  have  been  recommended,  but  subsequently  found  wlnl 
mg  m  power  to  cure,  although  they  may  have  power  to  give  tern- 
porary  rehef     Among  them  are  aconite,  Indian  hemp,  musT 
camphor   armca   nitrate  of  silver,  belladonna,  hyoseyamus    &c 
Strychma,  also,  has  been  highly  recommended.    Many  of  thes^ 
may  control,  somewhat,  the  distressing  symptoms.     The  iniection 

result.    Ice  has  been  used,  also,  to  the  spine,  with  the  view  of 

ta  "TcUtb"  ^''"'''  '"'  "  "-"^  P™-^  serviceable  fir  a 

me     Ice  w,ll  be  more  grateful  to  the  patient  when  given  to  hira 

to  take  m  small  p.eces;  these  he  can  often  swallo;,  with  mos" 

comfortmg  rehef.    Marshall  Hall,  while  pursuing  his  unwearied 

.use  ofV  ,^    7  ,.   '\""'  '"'•^"""y  "f  '"■™"'i»g  «s  the  final 
cause  of  death,  and  that  the  operation  of  tracheotomy  would  nrovc 
a  cure.    However,  by  such  a  course,  only  one  symptom  is  relieved 
The  disease  always  takes  a  steadfast  course,  whether  one  or  mor<; 

way  retard  the  fatal  course  of  the  malady. 


n 


i     r    ii    *: 


ff.l 


i      '     ill 
^  1  1  <  f 


I  111  ^ 

,  .1  J!'lij.,B'it  11 


256 


PRINCIPLES    OF    SURGERY. 


In  conclusion,  I  have  to  refer  to  the  proposed  cure  by  salivation. 
A  case  is  recorded  by  a  Dr.  Legget,  of  Maryland,  who  declares 
that  he  successfully  treated  a  colored  girl,  agod  twenty,  of  unmis- 
takable  hydrophobia,  by  the  administration  of  calomel  in  drachm 
doses.  Having  first  abstracted  blood  to  the  amount  of  Sxxxij,  he 
administered  the  drug  about  every  six  hours.  Under  this  treat- 
ment, the  paroxysms  gradually  subsided  in  force  and  frequency. 
The  ground  upon  which  he  based  the  treatment,  was  that  "the 
increased  flow  of  saliva  appears  to  be  a  conservative  effort  of  the 
vis  medicatrix  to  eliminate  the  poison  from  the  system^  through  the 
glands  engaged  in  its  secretion."  So  far  as  I  know,  this  remedy 
has  not  been  fully  tested.  But  it  is  to  be  feared  that  it,  like  so 
many  others,  will  fail  when  again  employed.  Yet  it  is  to  be  hoped 
that  the  advance  of  pathological  science  will  hereafter  enable  the 
profession  to  conquer  this  distressing  malady. 


CHAPTER    XXXII. 


Tetanus :  Symptoms— Stages— Pathology— Diagnosis— Treatment. 

Tetanus  —  Varieties. — There  are  two  kinds  of  this  disease,  the 
Idiopathic  and  the  Traumatic.  It  is  the  latter  which  the  surgeon 
,i8  called  upon  to  treat.  By  tetanus  is  understood  a  tonic  contrac- 
tion of  one  or  more  of  the  voluntary  muscles,  commencing  almost 
always  in  the  region  of  the  neck,  especially  the  muscles  of  the  jaw. 
Hence  the  cognomen  lockjaw.  It  is  essentially  a  nervous  disease, 
in  which  the  nervous  centres,  especially  the  medulla  oblongata, 
assume  a  function  decidedly  morbid. 

Its  Nature. — It  has  generally  been  supposed  that  in  traumatic 
tetanus  some  irritation  in  a  certain  part,  commonly  where  a  wound 
has  been  made,  acts  upon  the  nerves  therein,  creating  a  morbid 
action,  which  action  is,  after  a  time,  communicated  to  the  nervous 
centres ;  there  in  turn  to  establish  an  unnatural  condition,  which 
will  be  manifested  by  morbid  reflex  action,— the  phenomenon  above- 
mentioned,  that  is,  an  incessant  contraction  of  certain  muscles, 
which  will  continue  for  an  indefinite  period,  but  often  until  death 


TETANUS. 


257 


terminates  the  disease.     This  has  been  the  general  view  but  of 
late  the  question  has  been  raised    whether  f^o 
would  exhibit  a  condition  so  aTnorJl  It^^^^^^^  '''''"^ 

so  frequently  fatal,  if  the^e  were  nn^.'  '  a  termination 

rangement,  o'r  pred'ispo^  ioirdisetse  '^Zf^TT^''''  t 

tetanus  arises  without  any  appa  ent  l^erntl  '""'T^'' 

X  xf    ,  ^  «pp<ireni  exiernal  cause,  ffops  far  *n 

uppor.  th,s  latter  view,  namely,  that  in  order  that    he^llf  Li 
t>t,o„  may  produce  the  disease,  there  n,„st  have  previous  yerid 
some  spec,flcd,sease  of  the  blood,  engendered  perharby  thTde 
velopment  of  some  poison  akin  to  that  which  gives  riL  to  oyll 

certain  e.ects  upon  trhtlltltrr  trnditZ::; 
remain  m  a  latent  state  for  an  indefini  e  time      A.  ,    ,T    ^^^ 
.here  is  an  expression  of  disturbant  t  rnifestd  t  ^"S 
.  tetanus.    Now,  nliopathic  tetanus  is  comparatively  a  ZiMlZ' 
Md  rare  y  terminates  fatally;  at  least, 'under  tv„r:;":r 

form  may  be  recovered  from,  the  traumatic  rarely  does     rTt 

::rttiicr^~^'~^^ 

toe  but  quickly  extends  to  the  muscles  of  the  body      When  ,Z 

,   >vutn  inose  ot  the  back  alone  are  enira<^Pd   th^r^  ic 
17 


illt. 


I 


'  y. 


I 


'f! 


i*'l5 


llil 


I,  .  I 


fi 


258 


PRINCIPLES    OF    SURGERY. 


Opisthotonos.  Sometimes  the  disease  attacks  the  muscles  of  one 
side,  and  then  it  is  called  Pleuroathotonos.  And  sometimes  in  its 
intensity,  the  disease  affects  all  the  voluntary  muscles  of  the 
body,  so  that  it  is  immovable— rigid.  Here  we  have  essentially 
tetanus — the  disease  in  its  perfect  type. 

Causes. — The  causes,  to  repeat  somewhat,  are  local  and  general, 
or  predisposing  and  exciting.  The  general  cause  is  some  weakness 
or  poison  developed  in  the  systqm.  That  weakness  is  a  cause,  is 
seemingly  shown  by  the  fact  that  the  bleeding,  or  accidental  loss 
of  blood,  sometime  before  the  attack,  will  intensify  the  complaint. 
The  local  causes  are  wounds  or  injuries,  especially  such  as  involve 
dense  fibrous  structures,  which  have  a  free  supply  of  nerves.  In 
these  cases  the  nerves  themselves  are  generally  lacerated,  or 
otherwise  very  much  irritated.  There  are  certain  irritants  which 
seem  particularly  to  possess  the  power  to  light  up  the  disease,  the 
embers  of  which  had  been  laid.  The  rust  of  a  nail,  the  accretions 
upon  an  old  pin,  are  among  the  most  active  ones.  Exposure  to  ex- 
treme heat  and  cold,  are  said  to  be  exciting  causes  of  the  disease. 

Structures  subject.— W'UWg  the  disease  is  most  likely  to  occur 
in  connection  with  wounds  of  a  fibrous  structure,  it  may  also  fol- 
low wounds  of  the  face,  neck,  joints,  spermatic  cord,  as  well  as  of 
the  fingers  and  toes. 

Period  of  Incubation.— The  length  of  time  between  the  recep- 
tion of  the  wound  and  the  commencement  of  the  disease,  is  said  to 
vary  very  much,  indeed,  from  a  quarter  of  an  hour  to  a  month. 
There  are  cases  mentioned  in  Chelius  of  both  kinds.  When  the 
disease  presents  itself,  the  wound  may  be  yet  in  an  inflamed  state, 
or  healing,  or  suppurating,  or  a  cicatrix  may  have  formed. 

Stages— Symptoms  of  each.— The  disease  may  be  divided  into 
three  stages  (Chelius),  with  corresponding  symptoms.  In  the  first 
stage  the  muscles  about  the  neck  only  will  be  affected.  There  will 
be  a  sense  of  stiffness  like  that  which  accompanies  a  common  cold. 
The  larynx  and  muscles  of  the  tongue  are  unable  to  act  freely, 
i,ftU8ing  the  voice  to  appear  unnatural.  The  efforts  to  swallow 
cause  often  great  distress,  and  sometimes  terror,  especially  when  it 
is  water,  as  in  hydrophobia.  It  is  these  symptoms— the  changed 
voice  and  difficulty  of  swallowing,  which  have  produced,  some- 
times, difficulty  of  distinguishing  the  two  diseases  apart.  Their 
is  an  absence  of  inflammatory  symptoms,  but  sometimes  there 


TETANUS. 


259 


are  shootmg  pai„8.     In  the  part  wounded  there  may  be  unhealthv 
aeon,  or  .t  may  remain  unchanged.    After  a  time  the  slifCa  of 
the  muscles  about  the  neck  asanmes  the  form  of  lockjaw    and  the 
second  stage  ,s  mtroduced.     The  mouth,  now,  cannot  b    opened 
unless  w,th  great  difficulty,  cither  by  the  patie;t  or  surgeon     The 

t:Z:    Th  '  ^"tJ"^"""^  '"™  •'°™  "  '"earners  0 
he  mouth     The  eyel.ds  are  sometimes  firmly  shut,  the  iris  con 

trac ted,  the  eyeball  fixed,  and  there  is  an  acute    ensib  i';  t„ 

l.gh  .     Th,,  contracted  state  of  the  muscles  of  the  fac     'il  a 

most  unpleasant  expression  to  the  countenance,  which   ometimes 

becomes  h.deous.    The  muscles  of  the  abdomen  are  generXZ 

next  to  become  affected,  and  the  intestinal  canal,  S  ott  ^  X 

dommal  v.sccra  participate  in  the  affection;  and   here  is  conte" 

quently,  retention  of  stools,  and  of  the  nri.  ,     This  const'inrot 

.almost  always  present;  and  it  was  asserted  b.  ACrXylZ 

th,s  eons„pat,o„  was  the  determining  cause  of  the  malady    '0!^ 

s..pa„on  generally  precedes  the  tetanic  convulsions,  and  Ab  rnethv 

of  the  present  day  is.  that  ^r^:^:!:7Z:x:[::: 

Ihc  effect  of  the  morbid  condition  of  the  nerves  and  no,  » 

or  a  link  in  the  chain  of  causes.     At  this      rL  of  the  die":; 

.here  ,s  more  pam  experienced;  sometimes  severely  a  the  low" 

:::;;et;ossr""^'™-' '"«-'•"- 

The  Ih-rd  stage  is  introduced  by  ,ome  difficulty  of  brcathinir- 
he  muscles  of  respiration  begin  to  participate  in  the   pa     ,    oJ 
c«-muMy  the  contraction  is  so  deci.lcd  that  death  at  one.   lu!  " 
b.v  the  arrest  of  the  respiratory  function      Oftener  .U     •  ' 

and  continued  distress  of  breatl,i„„     iLl,  I  "  «''''"' 

0...-I  hy  the  disease  ex.::,   ^o  ,h     hean'  1:T'"'11' 
con,n,c,ion  of  muscles  about  the  fhroa    s  so  gr  at  ^CuTl 
™nont  ,s  arrested,  and  thus  death  will  be  pro   .c      bl  Ip    :!' 

isT  ./•"""«  «!'«  "hole  course  of  the  dis,  «e,  the  intellect 


!»,ii 


Vfl 


i:  ii. 

-I'fl 

ji 

Jim 

■Hi 

Kii 


1 


260 


PRINCIPLES    OF    SURGERY. 


Pathology.— Post-mortem  examinations  have  not  revealed  very 
much.  The  nerves  and  their  sheaths,  extending  from  the  wound 
toward  the  spinal  cord,  are  sometimes  found  inflamed.  In  the 
substance  of  the  brain  and  spinal  cord,  but  little,  if  any,  change 
can  be  detected.  They  are  sometimes  congested,  occasionally 
softened.  (Chelius.)  The  membranes,  however,  are  always  found 
congested,  especially  those  of  the  cord;  possibly  though,  the  gravi- 
tation of  the  blood  after  death,  may  assist  in  producing  the  latter 
condition.  Effusion  of  watery  fluid  between  the  membranes  is  not 
uncommonly  seen.  Recent  observations  show  that  the  medulla  ob- 
longata  is  generally  softened.  As  yet  there  is  not  sufficient  data 
to  establish  any  hypothesis. 

Dta^wom.— Hydrophobia  is  the  only  malady  for  which  tetanus 
may  be  mistaken.  But  if  the  history  of  the  case  and  the  charac- 
ter  of  the  spasms  be  studied,  there  cannot  be  a  mistake.  In  addi- 
tion,  the  diagnosis  will  be  assisted  by  noticing  the  condition  of  the 
mucous  membrane  of  the  mouth  and  throat.  In  hydrophobia  there 
is  an  undue  viscid  secretion;  in  tetanus  such  is  not  the  case. 

Prognosis.— In  the  traumatic  form,  it  is  always  unfavorable. 
But  few  cases  of  recovery  are  recorded.  The  danger  is  always  in 
proportion  to  the  acuteness  of  the  attack.  If  trismus  only  be 
present,  and  there  be  no  tendency  to  increase  in  the  intensity  of 
the  symptoms,  then  there  is  hope.  This  hope  will  brighten,  as 
day  after  day  passes  away  with  no  increase  in  the  severity  of  the 
symptoms.  South  says  "  if  seven  days  pass  away,  in  any  case, 
there  is  great  hope  of  recovery." 

Treatment.— The  pathology  of  the  disease,  so  far  as  understood, 
must  be  the  basis  upon  which  to  found  judicious  troatmont.  It  is 
essentially  a  nervous  disease.  The  blood  may  be  in  an  abnormal 
state,  or  other  morbid  conditions  may  exist,  which  have  led  to 
the  malady.  But  when  the  disease  is  before  the  surgeon,  he  finds 
the  nervous  system  principally  affected.  All  along  the  nerve- 
tracks-from  the  scat  of  the  wound  to  the  spinal  centres,  and  m 
those  centres  themselves,  and  then  along  the  nerves  procoed.ng  to 
supply  the  muscles,  which  in  this  disease  become  affected,  at  many 
points  and  in  a  degree  more  or  less  intense— may  be  foun<l  n-nta- 
tion.  No  doubt,  the  greater  the  aggregate  of  irritation,  the  more 
decidci  the  disease.  Taking  this  view,  it  can  readily  be  undor- 
atood  that  every  cause  of  irritation  should  be,  if  possible,  removed; 
the  irritated  parts  soothed  ;•  the  whole  nervous  system  soothcil 


TETANUS. 


261 


To  fulfil  the  former  indication,  to  remove  the  local  cause  of  irrita- 
tion   It  has  been  recommended  to  remove  or  destroy  the  part  in 
^M  the  wound  is  situated.    This  has  been  done  by  amputating, 
or  by  cutting  away  the  irritated  tissue,  and  also  by  the  application 
of  the  cautery.     Again,  it  has  been  recommended  to  divide  the 
trunks  of  the  nerves  leading  from  the  part,  by  incisions,  thereby 
severing  the  chain  of  causes  by  which  the  disease  is  supposed  to 
be  established.     Such  procedure  can  only  possibly  be  attended 
with  benefit  m  the  earlier  stages,  before  the  nervous  centres  have 
become  involved ;  nnd  even  then,  if  there  be  a  constitutional  affoc 
tion,  but  little  benefit  can  be  anticipated.     The  propriety  of  usinjr 
the  cautery  may  well  be  questioned,  as  it  will  rather  tend  to  in- 
crease than  to  allay  the  irritation.    If  any  kind  of  cautery  should 
be  employed,  the  actual  cautery  ought  to  be  selected,  heated  tho- 
roughly,  so  as  to  completely  and  promptly  destroy  the  irritated 
nerves      Sedatives  of  various  kinds  may  be  found  very  service- 
able, when  applied  to  the  wounded  part ;  perhaps  may  even  pre- 
vent the  general  disease. 

The  Constitutional  Treatment.-movta  will  be  directed  to  allay 
the  spasmodic  action  of  the  muscles,  and  to  secure  a  healthy  action 
of  the  excretory  organs,  and,  in  the  meantime,  to  sustain  the  pa- 
tient  s  strength.     Bleeding  was  formerly  practised,  but  with  little 
advantage;  indeed,  loss  of  blood,  it  is  seen,  renders  the  disease 
more  fatal.    Cupping  along  the  spine  has  been  attended  with  more 
benefit,  as  well  as  incisions  on  each  side  of  the  spine.     Purging 
with  croton  oil  or  elaterium,  ought  to  be  secured  as  early  as  pos- 
sible, assisted  by  injections,  if  necessary.      Sedatives  an.l  anti- 
spasmodics of  every  kind  have  been  tried,  but  with  indifleront 
success.    The  system  seems  to  have  acquired  a  tolerance  of  drugs 
80  that  tliese  medicines  are  to  a  great  extent  inert,  especially 
opium.    Bella.lonna  has  been  given,  witli  a  little  yet  no  permanent 
success,  in  doses  of  one,  two,  and  three  grains  of  the  extract. 
And  there  is  a  long  list  of  other  remedies,  which  have  been  re- 
commended  by  different  authorities:  such  as  Cannabis  Indica- 
tobacco,  and  warm  bathing;  colchicum  ;  blisters  along  the  spine 
with  sedatives  to  the  raw  surface ;  also  ice  along  the  spine  •  mer' 
cury;   chloroform.      But,   whatever  remedial  measures  may  be 
resorted  to,  there  is  an  absolute  necessity  for  powerful  tonics  and 
Htimulants.    These  must  be  freely  and  frequently  administered,  by 
jiiuutii  ana  per  rectum. 


,  na 


li 


iDX-wxsxoisr    IV. 


L 


iM  af 


DISEASES   OF   CERTAIN  TISSUES,    BONES,   JOINTS   (INCLUDING   FRAC- 
TURES  AND   DISLOCATIONS),   ARTERIES,    AND    VEINS. 

CHAPTER     XXXII  I. 

Diseases  of  Bone  :  Remarks— Classification— Course  to  be  Pursued— Inflam- 
mation of  Periosteum— Of  Bone— Causes— Symptoms— Local— General- 
Prognosis— Pathology— Terminations— Duration— Treatment  of  Acute- 
Chronic— Of  Products— Fibrin. 

Diseases  of  Bone.— Diseases  of  bone  have  their  points  of  pecu- 
liar interest  and  importance,  the  principal  two  of  which  are :  first, 
the  fact  that  the  bones  constitute  the  framework  of  the  system ; 
and  secondly,  that  they  are  quite  covered  up  by  the  soft  tissues. 
The  osseous  system  is  not  only  a  framework,  but  a  moving  one ; 
and  the  various  muscles  by  which  it  is  moved  have  their  various 
points  of  attachment  to  the  bones.  Consequently,  any  injury  or 
disease  of  the  bone  not  only  gives  rise  to  local  symptoms,  but  also 
interferes,  to  a  greater  or  less  extent,  with  the  movements  of  the 
body.  And  again,  the  bones  being  hidden  from  view,  it  is  more 
difficult  to  understand  the  changes  which  may  be  taking  place  in 
their  structure.  Therefore,  the  diagnosis  has  to  be  arrived  at  en- 
tirely fron^  external  symptoms  and  signs ;  and  consequently,  the 
surgeon,  in  treating  disease  of  the  bone,  will  have  to  give  the 
more  diligent  heed  to  those  points  of  diagnosis  which  are  dis- 
cernible. 

Classification.— Vnr'wns  classifications  of  the  surgical  afl'octions 
of  the  bone  might  be  gi\^n.  It  is  better,  however,  to  select  that 
which  is  most  practical— which  will,  by  cognomen  and  arrange- 
ment, afford  to  the  student  some  assistance,  not  only  to  avoid 
unnecessary  repetition,  but  to  simplify  the  subject. 

In  considering  inflammation  of  the  bone,  it  is  desirable  to  refer, 


DISEASES    OP    BONE. 


263 


in  the  first  place,  to  the  periosteum  and  endosteum.  Although 
these  membranes  are,  strictly  speaking,  fibrous  in  their  nature, 
yet  the  fact  that  they  are  the  textures  in  which  are  spread  out 
the  feeding-vessels  of  the  bone,  and  because,  when  in  any  way 
affected,  they  are  so  likely  to  cause  disease  of  the  bone  itself, 
renders  it  difficult  to  describe  the  affections  of  one  structure  with- 
out, at  the  same  time,  those  of  the  other. 

Following  the  course  pursued  in  the  consideration  of  the  general 
principles,  I  shall,  in  course,  speak  briefly  of  inflammation  of  the 
'periosteum,  and  the  products  thereof;  and  then  the  more  remote 
results,  viz. :  effusion  of  serum;  of  lymph;  suppuration;  inflam- 
mation of  hone;  necrosis;  hypertrophy;  induration;  atrophy; 
softening;  caries;  also  of  tubercle  in  hone;  cancer;  aneurisms; 
tumors;  wounds  of  hones;  and  finally  oi  fractures. 

Inflammation.— K^  before  intimated,  the  relation  between  the 
periosteum  and  the  bone  is  most  intimate;  consequently,  it  is  most 
difficult  to  say,  in  most  cases,  whether  the  disease  is  in  one  tissue 
or  the  other,  or  both.  Indeed,  the  disease  is  very  likely  to  extend, 
by  contiguity,  from  one  to  the  other.  The  usual  division  into 
acute  and  chronic  may  be  made;  yet,  in  many  cases,  the  inflam- 
mation assumes  the  form  of  the  subacute.  Indeed,  the  inflamma- 
tion, when  situated  in  the  bone  proper,  although  acute,  resembles, 
both  with  respect  to  its  course  and  the  symptoms,  the  chronic  in- 
flammation of  soft  structures.  Calling  to  mind  the  phenomena 
of  inflammation,  this  will  be  readily  understood.  Although  the 
bone,  like  other  tissue,  has  within  it  bloodvessels,  whose  function 
it  is  to  carry  blood  to  and  from  the  osseous  fibres,  and  has  absorb- 
ents, and  is  supplied  with  nerves  and  cellular  texture,  yet,  from  the 
dense  and  firm  nature  of  the  cellular  structure,  it  is  impossible  for 
the  same  changes  to  take  place  which  are  seen  in  inflammation  of 
the  soft  tissues.  In  fact,  the  inflammatory  process  is  less  rapid  in 
its  course,  and  less  certain  in  its  results.  Because  of  these  phy- 
siological facts,  it  was  fonncrly  supposed  that  inflammation  never 
occurred  in  the  bone.  But  the  advance  of  pathological  knowledge 
has  placed  these  diseases  on  a  proper  basis. 

Causes.— 1\\Q  causes  of  inflammation  of  the  bony  structure  and 
Its  membranes  may  be  divided  into  general  and  local,  or  into  pre- 
-iisposing  and  exciting.  As  a  general  thing,  the  intensity  of  the 
inflammation  corresponds,  in  an  inverse  ratio,  with  the  power  of 


^u 


'■t'f 


15 


mk\ 


\  i\ 


264 


PRINCIPLES    OF    SURGERY. 


the  predisposing  cause.  That  is  to  say,  when  the  constitutional 
cause  is  the  principal  actor  in  begetting  the  disease,  the  inflamma- 
tion will  not  be  so  acute ;  while,  on  the  contrary,  when  there  is 
but  a  slight  predisposing  cp-use,  a  more  potent  exciting  cause  being 
required  to  create  the  morbid  action,  the  inflammation  will  be 
much  more  severe. 

Constitutional  Causes. — The  most  important  constitutional 
causes  are  syphilis,  mercurial  poison,  scrofula,  impoverished  state 
of  the  system,  from  long  continued  exposure  to  cold  and  wet,  with 
insufficient  food.  Two  or  more  of  the  general  causes  will  often 
be  found  coexisting.  When  the  patient's  system  is  at  the  same 
time  vitiated  by  syphilitic  and  mercurial  poison,  there  seems  to  be 
not  simply  an  addition  of  the  two  poisons,  but  as  it  were,  a  multi- 
plication of  them. 

Local  Causes. — Are  injuries  of  various  kinds,  as  blows,  lace- 
rated wounds  extending  to  the  bone,  contusions,  fractures,  con- 
tinued pref'ic.re,  inflammation  in  neighboring  parts,  passive  conges- 
tion, resulting  from  improper  position  of  the  limb  and  interrupted 
venous  flow. 

Symptoms,  Local  and  General. — The  ordinary  local  symptoms 
of  inflammation,  pain,  heat,  redness,  swelling,  are  present ;  but  all 
of  them  are  not  equally  well  marked. 

Pain  is  always  present,  and  in  the  acute  form  is  always  most 
intense.  The  cause  of  this  intense  pain  will  be  obvious,  when  it 
is  remembered  that  the  bone,  and  also  the  periosteum,  are  unyield- 
ing, and  that  consequently  the  irritated  nerves  will  be  subject  to 
great  pressure,  as  the  tissue  becomes  congested,  and  the  products 
of  inflammation  eff'used  into  the  structures. 

Pain,  indeed,  is  so  constant  and  so  severe,  that  it  constitutes 
one  of  the  diagnostic  marks  of  the  disease.  The  pain,  always  acute, 
at  night  becomes  exquisite;  this  is  a  further  diagnostic  symptom. 
At  all  times,  the  slightest  pressure  made  over  the  part  will  cause 
the  most  excruciating  pain. 

Heat  is  never  very  great,  and  may  be  absent.  Redness,  in  the 
first  stage  is  generally  very  slight,  unless  the  bone  involved  is  sub- 
cutaneous. On  the  contrary,  the  skin  is  often  unusually  pale; 
but  as  the  inflammatory  action  continues  and  ov tends,  the  super- 
imposed integuinont,  however  deeply  seated  th"  bone  may  bo,  will 
become  graduaii;   red.     In  many  cases  tl  ■•  rclness  is  due  to  tho 


DISEASES    OP    BONE. 


265 


presence  of  venous  blood.  Swelling  at  first  is  not  very  percepti- 
ble,  yet  there  is  a  tense  and  full  condition  of  the  skin,  which  may 
be  detected  on  close  examination  by  the  eye,  or  the  finger.  This 
is  due  to  effusion  of  serum  in  the  subcutaneous  cellular  tissue. 

The  general  symptoms  are  well  marked.  The  very  great  pain 
quickly  creates  constitutional  disturbance  and  inflammatory  fever, 
with  all  its  concomitants  {vide  Inflammatory  Fever).  But  other 
constitutional  symptoms  not  unfrequently  attend  this  disease,  es- 
pecially  in  the  chronic  form.  These  symptoms  may  indicate  some 
predisposing  cause  of  the  disease,  and  will  be  due  to  some  taint  or 
faulty  condition  of  the  blood.  In  the  more  chronic  form,  there  is 
often  great  debility  of  the  constitution,  characterized  by  a  blood- 
less condition  of  the  skin,  emaciation,  loss  of  strength  and  spirits, 
want  of  appetite  and  sleep,  and,  when  the  patient  is  sinking,  there 
will  be  hectic. 

Diagnosis.— As  already  observed  it  is  impossible,  in  most  cases, 
to  decide  whether  the  periosteum  or  the  bone  is  involved,  and 
hence  periostitis  tind  ostitis  have  been  considered  as  one  disease. 
But,  while  it  may  be  impossible  to  decide  whether  the  bone  or 
membrane  is  the  seat  of  disease,  it  is  important  to  understand  the 
several  stages  of  the  disease,  and  to  distinguish  between  a  state  of 
mflammation,  and  a  state  due  to  the  results  of  the  inflammation, 
more  especially  of  caries.  Other  affections,  for  which  it  may  be 
mistaken,  are  rheumatism  and  gout.  But  by  duly  considering  the 
history  of  the  case,  as  well  as  the  local  symptoms,  the  surgeon  can 
hardly  go  astray  in  his  diagnosis. 

Prognosis.— This  must  be  very  guarded;  at  the  best  the  disease 
IS  often  tedious,  while  it  may  be  followed  by  the  most  serious  con- 
sequences to  the  bone,  recovery  from  which  will  be  anything  but 
rapid;  yet,  as  a  general  thing,  the  disease  is  not  fatal  to  life. 

Pathology.— In  every  disease  of  the  bone,  whether  it  be  inflam- 
mation or  the  result  of  inflammation,  a  correct  knowledge  of  tho 
pathology  is  of  essential  importance.  The  surgeon  ought  fully  to 
understand  and  watch  for  the  various  changes  which  may  occur  in 
the  progress  of  the  disease,  and,  as  accurately  as  may  be,  the 
several  symptoms  by  which  each  pathological  state  is  charac- 
terized. 

When  the  inflammation  is  established  in  the  membrane  which 
covers  the  bone,  or  which  lines  the  canal  within,  or  in  the  bony 


I   ■ 


266 


PRINCIPLES    OP    SURaERY. 


tissue  immediately  in  contact  with  either  of  these  membranes,  an 
event  may  suddenly  occur,  of  great  pathological  interest,  by  which 
the  bone  is  exposed  to  serious  danger;  this  occurrence  is  due  to  a 
rapid  eflFusion  of  serum,  the  first  product  of  inflammation,  between 
the  membrane  and  the  bone,  so  as  to  forcibly  separate  them,  and 
thereby  to  destroy  the  numerous  small  nutrient  vessels  by  which 
the  bone  is  supplied  with  blood.  The  natural  result  will  be  death, 
or  necrosis  of  the  bone,  which  had,  through  the  membrane,  been 
supplied  with  blood ;  and  then  must  follow  a  long  tedious  process 
of  sequestration  by  nature.  Again,  the  product  of  inflammation, 
poured  out,  may  be  liquor  sanguinis.  If  sufficient  in  quantity,  it 
will  also  produce  similar  immediate  results ;  and  when  this  is  not 
the  case,  destruction  of  the  bone  may  follow  by  a  more  protracted 
course.  The  liquor  sanguinis  may,  of  course,  be  absorbed;  but 
often  while  the  serum  will  separate  from  this  compound  and  be 
absorbed,  the  fibrin  will  remain  to  become  organized,  or  it  may 
degenerate  into  pus ;  in  the  former  case  the  coagulation  and  con- 
traction of  the  fibrin  will  tend  to  destroy  the  tiny  vessels.  Many 
of  them  may  be  embraced,  as  it  were,  and  perhaps  completely 
strangulated,  by  the  fibrin  contracting  around  them.  When  many 
of  them  are  completely  strangulated,  necrosis  inevitably  follows. 
But  the  vessels  may  be  only  embarrassed,  so  that  normal  nutrition 
is  impossible,  and  the  remote  consequence  will  be  a  diminution  of 
the  osseous  fibres.  And  the  weight  of  the  bone,  although  the 
general  bulk  is  in  no  way  changed,  will  also  be  lessened.  This  Is 
called  atrophy.  This  disease  may  be  due  to  other  causes,  but  in 
this  way  it  may  arise  as  a  result  of  inflammation  oi  the  bone,  or 
its  periosteum. 

Then,  the  inflammatory  lymph,  in  whatever  place  poured  out, 
may,  instead  of  coagulating,  degenerate  speedily  into  pus,  or  de- 
generations may  follow  ineffectual  eff'orts  to  organize.  Pus  thus 
formed  at  once  constitutes  an  acute  abscess,  which  will  be  attended 
with  well-marked  symptoms. 

But  the  lymph,  instead  of  existing  between  the  membrane  and 
bone,  may,  as  a  product  of  periostitis,  be  eff'used  in  the  substance 
of  the  membrane,  or  upon  the  outer  surface  of  the  membrane;  or 
it  may  simultaneously  exist  in  both  places,  and,  perhaps,  at  the 
same  time,  in  the  bone.  Wherever  it  may  be,  however,  there  will 
follow  organization,  or  degeneration.    Sometimes  the  organization 


DISEASES    OP    BONE. 


267 


is  accomplished  gradually.     This  is,  now  and  then,  seen  in  chronic 
periostitis,  or  when  the  inflammation  is  subacute.     The  effusion 
and  organization  are  occasionally  circumscribed;  more  frequently 
when  the  disease  is  due  to  syphilis.    There  may  coexist  in  different 
places  (in  this  constitutional  affection),  perhaps  in  different  bones, 
several  periostial  thickenings.     They  are  known  by  the  name  of 
syphilitic  nodes.     The  plastic  matter,  between  the  membrane  and 
bone,  may  undergo  a  very  perfect  development,  so  that  the  two 
will  become  so  incorporated  that  they  are  indistinguishable.     But 
at  any  time  during  the  process,  degeneration  may  supersede  de- 
velopment, and  be  followed  by  death  and  disintegration,  not  only 
of  the  adventitious  material,  but  as  well  the  original  tissue  in 
which  the  effusion  had  taken  place.     In  this  way  extensive  and 
formidable  destruction  often  occurs  in  the  progress  of  constitu- 
tional syphilis,  constituting  tertiary  symptoms.     I  have  observed 
them  very  frequently  on  the  bones  of  the  head  and  upon  the  tibia. 
{Vide  Syphilis.) 

When  the  inflammation  involves  the  bone  proper,  we  will  meet 
with  other  changes  than  those  just  described.     In  the  course  of 
the  first  stage  (active  congestion),  although  there  is  no  swelling 
externally  in  the  soft  parts,  there  is  actually  swelling  of  the  bone. 
It  soon  loses  its  natural  density,  the  interstices  of  the  bone  being 
occupied  by  the  products  of  inflammation.    The  vessels  in  the  bone 
being  engaged,  gives  a  bright  red  appearance.     As  the  effusion 
gradually  increases,  the  osseous  fibres  are  separated,  and  thus  the 
bone  is  literally  swollen.     The  separation  of  the  fibres  may  cause 
a  rupture  of  the  vessels,  so  that  here  and  there  will  exist  small 
clots  of  blood.     This  state  continuing  for  some  time,  the  osseous 
fibres,  constantly  pressed  upon,  will  be  gradually  absorbed,  so  that 
the  body  of  bone  will  be  left  soft  and  spongy.     If  at  any  time  the 
inflammatory  process  be  arrested,  the  fibrin  which  has  been  effused 
into  the  widened  interstices,  if  not  speedily  coagulating,  may  be 
absorbed,  leaving  the  bone  atrophied;   or,  on  the  contrary,  the 
adventitious  matter  may  become  organized  and  incorporated  with 
the  normal  tissue,  causing  induration,— another  disease  of  the 
bone.    But,  the  bone  being  swollen  at  the  time  the  fibrin  becomes 
organized,  there  results  not  induration  alone,  but  also  hypertro- 
phy,—yet  another  disease.     And,  when  a  long  bone  is  almost,  or 
altogether  inflamed,  the  swelling  attending  will  cause  lengthening, 


♦I 


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.%{■ 


268 


PRINCIPLES    OP    SURGERY. 


as  well  as  thickening.  This  hypertrophy,  although  spurious,  is 
seemingly  complete.  Should  there,  however,  be  no  swelling  when 
the  coagulation  of  fibrin  commences,  there  will  be  simply  indura- 
tion. 

The  adventliijrr,  matier  may  in  time  be  superseded  by  natural 
bony  tissue,  and  if  there  has  been  no  swelling,  the  recovery  will 
be  complete;  but  if  there  should  have  been  swelling,  then  the 
bone  (when  the  natural  shall  have  superseded  the  adventitious) 
will  be  truly  hypertrophied.  When,  however,  the  fibrin  which 
occupied  the  swollen  bone  is  shortly  rf-moved  by  the  absorbents,  it 
will  leave  the  bone  unusually  large,  although  atropi  led.  Again, 
the  liquor  sanguinis  may  continue  to  occupy  the  interstices  until 
the  osseous  fibres  are  almost  entirely  absorbed;  in  which  case, 

when  the  inflammation  sub- 
sides, the  bone  will  be  found 
softened:  a  condition  which 
may  continue,  there  being 
insuflicient  power  in  the  bone 
to  recuperate.  Thus,  it  will 
be  seen  that  the  inflamma- 
tory process  m-sy  terminate 
in  any  one  of  mostly  all  of  the 
more  important  diseases  of 
the  bone,  and  that  a  compa- 
ratively little  thing  may  turn 
the  disease  from  one  course 
to  another. 

Nature  will  put  forth  her 
efforts  to  repair  the  bony  tis- 
sue when  diseased;  but  it 
often  happens  that  these  ef- 
for  ^  are  unsuccessful,  the 
result  of  which  is  a  condition  of  the  bone  analogous  to  that  which 
is  observed  in  the  soft  parts  when  the  healing  process  fails.  This 
is  called  caries.  The  fibriuj  which  was  intended  to  act  a  primary 
part  in  the  process  of  repair,  fails  in  its  duty,  and  perishes  in  the 
attempt  to  perform  it,  and,  at  the  same  time,  very  often  involves 
the  original  tissue  in  its  own  destruction.  Two  or  more  of  the 
above  diseases  may  coexist  in  the  same  bone ;  and,  occasionally, 


DISEASES    OF    BONE. 


269 


>ne  course 


there  may  also  be  seen  one  or  more  of  those  diseases  in  a  part, 
while  m  another  part  nature  may  be  successfully  effectinK  repair 

In  conjunction  with  caries,  when  efforts  are  being  made  to  re- 
pair, there  will  sometimes  be,  instead  of  natural  healing  of  bone 
bony  deposits  m  an  abnormal  form,  in  shape  of  growths;  these 
are  called  osteophtes.  Or  it  may  be  upon  the  periosteum,  consti- 
tuting .a:o«^..e«,  soft  or  hard.  The  same  deposit  may  take  place 
upon  the  endosteum,  or  even  in  the  canals  or  the  lacuna ;  in  either 
case  It  may  be  like  the  natural  bone,  or  it  may  be  ivorv-Iike. 

It  may  be  stated,  as  a  general  fact,  that  mostly  all  of  the  dis- 
eases of  the  bone  which  come  under  the  notice  of  the  surgeon  are 
due  to  the  inflammatory  process,  and  the  eflTorts  of  nature  there- 
after to  heal. 

follows  •'''"''''''''''*  '^  ^'''''''''*  ^"^  ''''''*  """^  ^'  '^""'''^'^  ^' 
1.  Resolution  2.  Organization  of  plastic  matter,  which  has 
been  effused.  3.  Degeneration  of  it  into  pus.  4.  Partial  deve- 
lopment of  the  adventitious  matter,  and  subsequent  death  and 
disintegration.     5.  Necrosis.     6.  Softening.     7.  Induration.     8 

i/CsTot  '  ^'''''"  ''' '-'-  '''  ^-y  ^--^«- 

Length  of  Time.-The  length  of  time  required  for  the  inflam- 
mation to  run  its  course,  will  depend  upon  the  intensity  of  the 
u .sease  The  acute  form  may  terminate  in  a  few  days,  in  one  way 
or  another ;  but  when  one  of  the  other  diseases  follows  as  a  result 
the  course  is  always  tedious.  The  chronic  form  is  slow  from  the 
beginning. 

Bones  most  Liable.-The  bones  of  the  body  most  liable  to  in- 
flammation are  those  which  are  exposed  to  injuries  and  the  wea- 
ther, as  the  tibia,  ulna,  clavicle,  sternum,  and  cranium. 

Treatment  of  Acute  Periostitis.-First,  the  local.  Bearing  in 
mmd  that  the  .in  is  great,  and  the  cause  of  that  pain,  the  first 
step  to  be  tak.  a  is  fully  indicated.  In  the  first  place,  there  must 
be  absolute  rest,  and  due  attention  paid  to  position ;  then  every 
endeavor  used  to  allay  the  pain-to  remove  its  cause.  Immediate 
resort  should  be  had  to  hot  fomentations,  either  alone  or  in  con- 
junction  with  anodynes.  When  the  bone  is  subcutaneous,  the 
eftec  may  be  very  prompt  and  satisfactory.  They  must  be  dili- 
gently employed.    Occasionally,  a  hot  poultice  may  take  the  pla.e 


;  \ 


If  fir 


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m 


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270 


PRINCIPLES    OP    SURGERY. 


of  the  fomentation.  The  tendency  of  these  applications  is  to 
relax  the  dense  tissue,  and  thus,  directly  and  indirectly,  soothe 
the  nerves.  The  effect  is  produced  through  the  cutaneous  nerves. 
Cold,  as  a  sedative,  is  sometimes  employed ;  but  its  efficacy  is  not 
so  certain  as  that  of  the  hot  applications.  Sometimes,  local  ab- 
straction of  blood  is  necessary ;  this  may  be  done  by  leeches,  or 
by  incisions.  In  the  earlier  stage  of  the  disease,  leeches  will  suf- 
fice; but  afterwards,  the  incisions  may  be  necessary.  Blisters 
have  been  recommended ;  but  in  the  acute  form,  they  will  more 
likely  aggravate  the  disease — at  the  least,  the  using  of  them  will 
interfere  with,  or  take  the  place  of  other  agents  of  more  certain 
value.  In  the  mean  time,  measures  will  be  taken  to  subdue  the 
constitutional  fever.  Endeavor  to  get  the  various  excretory  organs 
in  healthy  working  condition;  reduce  the  heart's  action;  observe 
low  diet;  and,  according  to  some  authorities,  exhibit  mercury — 
instead,  however,  I  should  recommend  the  nitrate  of  potash,  or 
the  iodide.  The  treatment  must  be  prompt,  inasmuch  as  the  dis- 
ease runs  a  speedy  course,  and  disastrous  results  may  quickly 
follow. 

When  the  pain,  although  it  has  already  been  severe,  suddenly 
becomes  more  intense,  with  a  corresponding  increase  of  the  other 
symptoms,  there  is  reason  to  suppose  that  effusion  has  taken  place 
between  the  membrane  and  bone,  and  it  becomes  the  duty  of  the 
surgeon  to  promptly  relieve  this  condition.  Fomentations  or  ab- 
straction of  blood  will  not  suffice;  there  must  be  a  subcutaneous 
incision  indirectly  made  to  the  bone,  so  as  to  incise  the  periosteum, 
and  thereby  allow  the  pent-up  effusion  to  escape  into  the  cellular 
tissue  around  the  bone.  By  this  procedure,  necrosis  of  the  bone 
may  be  averted.  The  incision  does  not  require  to  be  very  large 
to  allow  the  effused  fluid  to  escape.  It  will  soon  heal  by  ad- 
hesion. 

Treatment  of  Chronic  Periostitis. — The  treatment  thus  far  has 
referred  especially  to  the  acute  form  of  the  disease ;  but  in  many 
cases,  the  periostial  inflammation  is  more  or  less  chronic.  In  such 
cases  the  treatment  will  be  less  heroic,  but  none  the  less  decided. 
In  every  case,  however,  it  is  equally  important  that  full  attention 
be  given  to  rest  and  position.  The  constitution  being  generally  at 
fault,  it  must  from  the  first  receive  specific  attention.  The  pecu- 
liar taint  which  had  acted  as  a  constitutional  cause  of  the  disease, 


DISEASES    OF    BONE. 


271 


must  obtam  that  particular  attention  which  its  nature  demands 
Local  abstraction  of  blood  will  not  commonly  be  required;  bui 
should  acute  symptoms  present  themselves,  which  will  occasionally 
happen,   then  the  treatment  suitable   thereto  will  promptly  be 
adopted.     But  as  a  general  thing,  the  treatment  will  consi'st  of 
comter-zTntation,  blister,,  or  the  application  of  the  tincture  of 
iodine.    The  iodine  is  more  particularly  useful  in  certain  stages  of 
nodes      It  acts  as  a  stimulant   somewhat,  and  creates  a  more 
healthy  action,  which,  superseding  the  chronic  inflammatory  ac 
tion,  assists  nature  to  remove  the  adventitious  matter  which  has 
been  deposited.     The  constitution  must  be  invigorated  by  proper 
dietary  measures,  as  well  as  by  attention  to  those  principles  de- 
tailed  more  particularly  in  connection  with  syphilitic  disease. 

Treatment  of  Remote  ProductB.~\^,  the  treatment  of  organized 
plastic  matter-a  more  remote  result  of  inflammation  of  bone  and 
the  membranes-the  surgeon  will  duly  consider  what  is  the  proba- 
ble amount  or  extent  of  those  results ;  what  has  been  the  effects 
upon  the  tissue ;  and  what  has  been  the  nature  of  the  efforts  made 
by  nature  to  repair;  and  to  what  extent  they  have  been,  and  will 
probably  be,  successful.     The  lesson  has  already  been  learned 
that,  by  natural  steps,  repair  may  be  effected,  and  the  products  of 
inflammation  either  removed,  or  so  modelled  that  the  tissue  will  be 
restored  to  its  normal  usefulness.    But  in  the  bone,  just  as  the 
inflammatory  process  is  slow  in  its  course,  so  is  the  subsequent 
reparative  process;  yet,  at  the  same  time,  the  work  is  being  ac- 
complished in  a  perfectly  healthy  manner,  and  no  art  can  possibly 
accelerate  the  operation.     The  duty  of  the  surgeon  will  consist  as 
much  m  seeing  that  too  much  is  not  done,  as  well  as  in  adminis- 
tering to  the  actual  requirements  of  the  case.     I  have  too  often 
seen  a  second  and  fatal  attack  of  inflammation  produced  by  inju- 
dicious efforts  to  promote  the  removal  of  the  organized  products  of 
ostitis  and  periostitis.     The  bone  in  which  it  is  placed  is  often  but 
little  able  to  resist  the  effects  of  this  second  attack  of  disease,  and 
canes  may  very  quickly  ensue.     Nothing  is  more  likely  to  give 
nse  to  this  than  overstimulating  applications;  or  hot  applications, 
after  inflammation  has  subsided.     Counter-irritation  may  occa- 
sionally  be  cautiously  employed;  but  the  principal  indications  are 
a  maintenance  of  rest  and  attention  to  the  constitution,  with  a 
view  of  insuring  healthy  action.     When  the  bloodvessels  of  the 


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1 

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272 


PRINCIPLES    OF    SURGERY. 


bone  are  much  impaired,  the  footsteps  of  nature  will  be  very  slow, 
and  the  surgeon  can  but  wait.  There  are,  of  course,  certain  me- 
dicines which  do  act  upon  the  absorbents,  and  which,  it  might  be 
supposed,  would  hasten  the  removal  of  the  adventitious  matter; 
but  it  must  be  remembered  that  the  normal  bone  is  incapacitated 
for  quick  action,  and  no  drug  can  cause  it  to  perform  extraordi- 
nary work  in  the  process  of  repair.  Again,  mercury  has  been 
recommended,  with  the  view  of  producing  liquefactive  degenera- 
tion of  the  organized  material.  That  it  may  have  such  an  effect, 
there  can  be  no  doubt ;  but  the  danger  is,  that  the  effects  of  the 
drug  will  not  be  limited  to  the  adventitious  matter,  but  that  it  will 
also  destroy  the  feeble  natural  tissue  as  well.  There  are  too  many 
cases  in  which  destructive  caries  have  thus  arisen,  which  have 
come  under  my  own  observation,  to  allow  me  to  say  one  word  in 
favor  of  mercury  in  such  cases. 

Treatment  of  Degenerated  Fibrin^  in  connection  with  Bone. — 
First,  of  pus.     It  may  collect  in  the  form  of  an  abscess,  between 

the  bone  and  periosteum  ;  in  the  sub- 
stance of  the  bone  ;  or  in  the  medul- 
lary canal ;  and  it  may  be  the  result 
of  periostitis,  or  ostitis,  or  of  both. 
The  symptoms  of  acute  abscess  are 
generally  well  marked ;  the  pain, 
particularly,  is  very  great,  and  no- 
thing less  than  an  incision  will  do. 
It  must  be  made  directly  down,  and 
sufficiently  large  to  allow  a  free  dis- 
charge of  the  pus.  This  will  be 
easily  done  when  the  pus  is  bet>yeen 
the  membrane  and  bone ;  but  when 
it  is  collected  in  the  osseous  struc- 
ture, or  in  the  meduMary  canal,  it 
will  be  more  difficult  to  perform; 
yet  the  same  course  must  be  pur- 
sued, provided  the  location  of  the 
abscess  io  known.  The  acute  ab- 
scess is  mostly  superficial,  while  the 
chronic  is  more  frequently  deeper  seated.  In  the  latter  case,  the 
symptoms  are  not  so  well  nuuke«  ,  and  the  diagnosis  is  less  cor- 


DISEASES    OP    BOKB. 


278 


ItunUf  ttlr  ""* '''V*"'^  "«-=?  '»  operate,  either  on 
.ecount  of  the  pain,  or  the  danger  to  the  bone  or  the  natient  la 
acute  abscess,  the  formation  of  pus  will  be  indicated  by  the  treat 
pa,n  beeon..ng,  fcr  a  time,  even  greater;  then  a  alight  Lwdfnee 
and  a  the  ean,e  time  a  ehill.  In  ehronic  abscess,  there  is  ne  such 
rehable  .nd.cation  of  suppnratien.  Although  th  re  iH  „  wh it 
..  often  severe  .t  is  not  so  exquisite,  and  it'comes  on 'gradual 

times  to  be  taken  for  rheumatic  pain.    It  is  more  of  a  dull  „r 
aohmg  character,  and  gives  a  sensation  of  being  deep-seated 

dial: s"'m*^ r "" '"'"' ""^'^""^ '» -ive at r:  ; 

diagno  s.    When  chrome  suppuration  takes  place  in  lone  it  is 
generally  after  some  injury,  or  an  attack  of  Lflam^at  on  'which 
had  entirely  subsided.    Although  convinced  that  there  is  nls 
there  remains  the  difficulty  of  deciding  the  question  of  laiu;' 
The  operation  consists  in  making  an  incision  with  the  knife  to  th^ 

rumen"  rstnT'tim:"""''  "  '  """  -"'""^  '»  "^  "« 

«Uar  dea,h-d,„ntet,ration.-'rh\s  is  found  to  occur  in  consTitu 
.ions  of  a  low  or  cachectic  character.     The  fibrin,  origin    lypr 

pemhes,  but  before  ,t  dies,  ,t  may  have  caused  serious  injury  to 
the  nutrient  vessels,  and  to  the  tissue  in  which  i,  was    feed 

aestrnetioi  of  the  tissue  in  which  it  has  been  deposited.    There  is 

ul  ciative  destruction.     This  form  of  disease  is  often  seen    „I 

ony  in  scrofulous  constitutions,  but  also  in  the  eas   of  syphi,  t  c 

0  OS,  more  especially  about  the  cranium.     The  only  thin'/ 

tae  m  the  way  of  treatment,  i,  ,o  treat  the  consfitntio*  gene! 

.lly;    ndeavor  to  renovate  it;  in  the  mean  time,  using  suclU    L 

pplieations  a.  will  tend  to  limit  the  ulcerative  p  ocess  a,  d  f.cili 

: :: :,  x:!  """""-"r  -'  "■-  "'-"■""  ^°"'"^™  "^- "  ' 

"r       „7  "  P"'"'  "f*"""^  »»■'  i"«liility  to  digest  food.     Thi. 
2  n  will  have  to  be  coaxed,  under  such  dreumsLces,  by  „si„« 

»ig«us  of  the  body  may  be  weak,  and   rrn„i„  .1. 


18 


f    « 


'H 


274 


PRINCIPLES    OF    SURGERY. 


1    -i 


Sometimes  the  pain  in  the  part  is  very  distressing,  especially  in 
nodes  upon  the  cranium,  necessitating  the  administration  of  ano- 
dynes. The  bowels  must  be  kept  regular.  As  to  medicines,  the 
various  preparations  of  iron  will  be  found  beneficial.  But  the 
iodide  of  potassium  will  prove  to  be  particularly  useful;  it  de- 
servedly enjoys  a  high  reputation  in  all  such  diseases.  Mercury, 
which  formerly  was  exhibited  in  these  cases,  is  in  most  instances 
decidedly  contra-indicated.  There  is  already  a  want  of  vitality ; 
there  is  already  a  disintegration  of  tissue,  both  of  the  natural  and 
the  adventitious ;  and  more  than  that,  there  is  often  extensive  de- 
struction in  consequence  of  the  use  of  this  drug.  Therefore,  no 
medicine  which  tends  to  lessen  vitality  can  with  propriety  be 
administered.  There  will  arise  cases  in  syphilis  in  which  mercury 
may  be  given,  but  they  are  quite  exceptional.  ( Vide  Syphilis.) 
The  local  treatment  will  depend  upon  the  condition  of  the  part, 
and  will  be  based  upon  principles  laid  down  in  the  treatment  of 
chronic  ulcers. 


CHAPTER    XXXIV. 


NocrofiiB:    Kinds -Soquostration-vSymptonis-Trofttment.      Softening  of 
Bore;    Kinds-Rickets-Diugnosis-Treatment.     Hypertrophy  and  Indii 
TBtion  of  Bono— Atrophy— Causes  of  Each. 

Necrosis,  or  Death  of  Bow e.— This,  as  ha,s  been  elsewhere  fully 
described,  may  be  the  result  of  periostitis,  or  ostitis,  accompanied 
by  effusion  ;  or  of  destruction  of  the  bloodvessels,  caused  by  coagu- 
lation of  fibrin  around  the  vessels,  or  of  laceration  of  the  vessels; 
or  from  injuries,  by  which  the  periosteum  is  stripped  off  the  bone; 
indeed,  anything  which  cuts  off  the  supply  of  blood  necessary  to 
life  in  the  bone.  The  result  is  death,  not  gradually  taking  place, 
but  at  once ;  not  in  molecules,  but  in  a  mass,  mm'  or  less  large. 
The  nutrient  vessels  which  have  been  destroyed  nmy  be  in  the 
periosteum  alone ;  and  supposing  it  to  bo  a  long  bone,  the  portion 
of  bone  which  dies  will  be  in  the  outer  portion  of  the  shaft.  Thin 
will  constitute  external  necroeis.  Or  the  vessels  affected  may  rc- 
Bido  in  the  endosteum,  when  the  effect  will  be  death  of  a  portion 


NECROSIS. 


275 


of  the  ^nner  part  of  the  shaft,  constituting  internal  necrosis. 
But  sometimes  the  vessels  both  within  and  without  the  shaft  are 
destroyed,  in  which  case  there  will  follow  death  of  a  portion  of 
the  whole  shaft.     This  is  called  complete  necrosis 

Those  bones  which  are  dense  in  structure  are  more  readily  de- 
prived of  hfe  than  those  which  are  more  cancellous  in  structure 
these  latter  being  more  subject  to  caries.     Certain  portions  of  the 
same  bone  are  often  predisposed  to  necrosis,  and  other  portions  to 
caries,  tor  the  same  reason. 

When  a  portion  of  bone  dies,  the  mass,  although  thereafter  to 
be  a  foreign  body,  necessarily  remains,  for  a  time,  in  a  condition 
resembling  almost  a  state  of  nature:  that  is  to  say,  the  osseous 
fibres  of  the  .lead  bone  are  continuous  with  those  of  the  livin<. 
and  the  character  and  appearance  of  the  dead  portion  do  not 
quickly  change.     Steps,  however,  are  soon  initiated  to  effect  a 
separation  of  the  living  from  the  dead  structure,  and  in  due  time 
a  line  of  demarcation  is  established  between  them.     The  line  of 
separation,  however,  is  by  no  means  uniform ;  all  of  the  osseous 
fibres  do  not  divide  at  the  same  point.     Consequently,  when  the 
dead  bone  IS  completely  sequestrated,  there  will  be  seen,  on  every 
81  e,  spicule,  of  bone  projecting,  with  corresponding  depressions 
The  process  by  which  this  separation  is  accomplished  by  nature  is 
most  interesting  and  instructive. 

At  the  commencement,  in  the  immediate  neighborhood  of  the 
hfoless  bone,  active  congestion  will  be  seen  to  exist.     Seemingly, 
the  blood  which  was  intended  to  support  bone  now  dead,  but  in 
winch  It  can  no  longer  circulate,  fills  to  repletion  the  cancelli  of 
the  neighboring  bone,  and  even  the  canaliculi  will  be  found  en- 
gorged  with  fluid.     This,  which  is  the  first  step  in  the  inflamma- 
tory process,  is  the  first  step  also  to  secure  sequestration  of  the 
(load  bone.     In  consequence  of  the  congestion,  the  osseous  fibres 
will  Dogin  to  softer,  at  the  point  where  vitality  ceases.     The  fibres 
prossod  upon  are  steadily  absorbed,  until  the  work  of  dividing 
t  em  ,H  complete,!.     This  absorption  must  be,  in  the  main,  if  not 
a  together,  at  the  expense  of  the  living  bone.     Possibly  some  of 
the  dead  tissue  may  be  acted  upon  eheuiically  where  the  structure 
|3  softened,  but  ,t  must  bo  very  limited  in  quantity.     It  is  stated, 
however,  by  a  recent  writer,  that  more  of  the  dead  bone  i/,  aU 
Horbcd  than   has   been   supposed.   (System   of  Surjrery.^      Tlu. 


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276 


PRINCIPLES    OF    SURGERY. 


action  by  which  the  work  is  done  can  be  accomplished  under  phy- 
siological rules ;  that  is,  the  congestion  need  not  exceed  a  point 
beyond  which  the  accruing  lymph  could  not  be  preserved  from  de- 
generation into  pus.     At  the  same  time,  not  unfrequently  pua  is 
generated,  and  occupies  to  a  greater  or  less  extent  the  space  which 
exists  between  the  dead  and  the  living  portions.     In  other  words, 
the  sequestration  may  be  done  by  physiological  action,  and  there- 
fore without  any  real  pain,  or  anything  to  indicate  the  action. 
But  in  other  cases,  the  congestion  is  so  great  as  to  cause  effusion 
of  lymph,  which,  unable  to  become  organized,  degenerates  into 
pus.     This  latter  method  may  be  considered  pathological,  because 
it  is  not  necessary  to  the  fulfilment  of  the  work.     When  pus  is  a 
product  of  the  action,  the  separation  is  the  more  speedily  effected ; 
but  there  will  be  attending  it  many  of  the  symptoms  of  ostitis ; 
and  still  more,  there  will  be  more  extensive  destruction  of  the 
living  bone.     Whether  the  action  has  been  physiological  or  (the 
congestion  having  merged  into  true  inflammation)  pathological, 
the  sequestrum— ior  that  is  the  name  given  to  the  fragment  after 
the  separation  is  completed— vfiW  act  as  a  foreign  body,  and  give 
rise  to  irritation  and  that  sort  of  inflammation  which  is  always 
created  to  expel  any  foreign  body,  whatever  its  nature.     In  many 
cases,  the  disease  which  has  led  to  necrosis  will  have  been  inflam- 
matory, as  we  have  seen ;  and  pus  may  have  been  the  immediate 
result  thereof.    In  such  cases,  it  may  be  expected  that  the  process 
of  separation  will  also  be  attended  with  some  suppuration.    How- 
ever, as  there  will  be  an  opening  through  which  the  dincharge  may 
escape,  there  will  be  an  absence  of  the  symptoms  of  inflammation. 
But  oftentimes  this  channel  will  become  closed,  and  the  pus  col- 
lecting will  give  rise  to  all  the  symptoms  of  abscess. 

In  the  case  of  external  or  complete  necrosis,  the  sequestrum 
will  at  once  tend  toward  the  surface  of  the  body.  The  sbarp  spi- 
cuIjc  of  bone  will  at  every  motion  of  the  limb  produce  irritation; 
which  will  very  soon  give  rise  to  suppuration,  and  if  an  opening  to 
the  surface  do'not  exist,  an  abscess  will  form,  which  upon  being 
opened  will  disclose  to  the  surgeon  the  foreign  body  seeking, ... ! 
were,  its  exit  from  the  body.  It  will,  in  the  abscess,  have  been 
borne  somewhat  outward.  The  pus  having  free  exit,  there  will  be 
following  the  sequestration,  the  process  of  repair  ui)on  the  surfaaH 
of  the  bone  from  which  detachment  has  been  effected.     This  work 


NECROSIS. 


277 


at  repair  often  commences  before  separation  is  complete.  In  fact 
when  there  is  not  inflammatory  action,  the  work  of  actual  repair 
may  be  going  silently  on  at  the  time  the  fragment  is  being  dis- 
severed. As  soon  as  the  new  bony  tissue  does  begin  to  form,  there 
will  commence  a  constant  pressure  upon  the  sequestrum,  by  which 
it  will  gradually  be  forced  toward  the  surface.  These  are  the 
agencies  by  which  nature  will  endeavor  to  rid  herself  of  the  foreign 
body.  It  will  be  seen  that  although  separation  of  the  bone  may 
be  effected  without  suppuration,  the  sequestrum  cannot  exist  with- 
out  producing  it— that  it  is  indeed  necessary  to  expel  it  from  the 
body.  But  the  surgeon  ought  to  assist  nature.  Until  separation 
IS  complete,  the  only  duty  of  the  surgeon  is  to  see  that  nature  is 
aLowed  to  work  unembarrassed.  The  channel  from  the  surface 
to  the  sequestrum,  through  wh.on  it  can  be  examined,  is  called  the 
cloaca. 

The  above  are  the  simple  but  efBcient  steps  by  which  the  se- 
questrum is  expelled  in  the  external  and  complete  forms  of  the 
disease.     But  in  case  of  internal  necrosis  the  work  is  by  no  means 
so  easily  accomplished.     The  dead  bone  is  incased  in  the  living, 
through  which  an  avenue  must  be  made,  that  it  may  be  released! 
To  accomplish  this  nature  is  often  adequate.     This  living  bone 
which  encircles  the  dead,  will  be  more  or  k.is  softened  by  the  pro- 
cess of  sequestration;   and  if  inflammation  attend,  which  is  not 
unlikely,  ulcerative  destruction  of  the  surrounding  bone  may  take 
place  so  as  to  eiTect  an  opening.     At  all  events,  when  the  detach- 
ment  is  completed,  the  foreign  body  will  provoke  inflammatory 
action,  followed  by  softening  of  the  surrounding  shell  of  bone. 
The  process  of  softening  occurring  in  one  or  more  places,  the  pus 
which  is  pent  up  will  escape  into  the  external  soft  tissue,  and  in 
time,  from  the  body.     Through  t'    ^e  channels  nature  will  essay 
to  expel  the  sequestrum.     When  die  dead  bone  is  of  large  size,  it 
cannot  possibly  find  exit,  and  will  re  vain  for  an  indefinite  period 
of  time,  cauHing  a  most  disagreeable  (though  not  necessarily  a 
painful)  purulent  discharge,     f  rora  time  to  time  the  sinus  may 
close,  upon  which  t.i,(.  pas  will  collect,  giving  rise  to  pain  and  un- 
easiness, which  v'.U  bp  followci  by  a  reopening  of  the  abscess.    In 
time,  the  mcloHeu  suquestrum  may  disintegrate,  under  the  influence 
of  heat  and  moisture;  but  the  process  is  very  slow. 
When  there  is  complete  necrosis,  that  is  when  a  portion  of  the 


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278 


PRINCIPLES    OF    SURGERY. 


whole  shaft  is  dead,  as  soon  a^  the  dead  bone  is  separated  from 
the  living,  and  even  before,  the  limb  may  be  incapacitated  for  use. 
But  nature  takes  early  steps  to  meet  this,  and  to  supply  a  substi- 
tute. The  congestion  which  causes  the  separation,  also  leads  to 
the  deposit  of  bony  matter  ail  around  the  shaft.  This  will  con- 
tinue to  form  until  a  very  complete  ease  will  surround  the  necrosed 
hone.  When  this  condition  is  produced,  there  is  a  close  resem- 
blance to  internal  necrosis;  for  this  shell  of  bone  may  become 
very  hard,  even  harder  than  original  bone.  While  the  shell  of 
bone  is  thus  forming,  there  will  remain  a  number  of  openings 
through  it  by  which  the  discharge  will  continue  to  take  place.  By 
the  formation  of  this  case  of  new  bone,  the  shaft  will  become  con- 
siderably Ic^rger.  During  the  progress  of  these  somewhat  com- 
plicated proceedings,  there  will  be,  from  time  to  time,  a  good  deal 
of  local  pain  and  constitutional  irritation. 

Sometimes  the  death  of  bone  upon  the  surface  will  be  so  limited 
that  merely  a  thin  scale  will  be  separated;  this  is  commonly 
designated  exfoliation. 

Symptoms  of  Necrosis — Diagnosis. — There  will  have  been  some 
injury,  or  inflammation,  the  symptoms  of  which  need  not  here  be 
repeated.  Those  symptoms  manifested  in  connection  with  the  his- 
tory of  the  case,  will  assist  in  arriving  at  a  correct  diagnosis  of  the 
diseaso.  Necrosis  has  been  divided  by  writers  into  three  stages: 
the  inflammatory,  the  stage  of  detachment,  the  stage  of  reparation. 
Many  symptoms  of  each  of  these  stages  nave  already  been  adverted 
to  in  connection  with  the  pathology.  When  the  necrosis  is  the 
result  of  inflammation,  and  there  is  as  yet  no  opening  externally, 
there  may  be  some  obscurity  in  the  diagnosis.  Necrosis  may  be 
suspected,  or  feared,  but  it  cannot  be  positively  known.  But  if 
the  dying  bone  is  accessible  to  the  eye,  or  by  the  probe,  the  con- 
dition characteristic  of  death  may  readily  be  detected.  When  it 
has  resulted  from  an  injury,  in  which  a  wound  has  been  made  in 
the  soft  parts  and  the  periosteum  stripped  off,  the  eye  can  easily 
discover  the  first  changes  toward  death.  When  the  formation  of 
an  abscess  precedes  the  existence  of  a  cloaca,  then,  as  before  said, 
the  surgeon  must  wait  until  a  way  is  open  for  the  probe.  The 
«ound,  or  sensation  produced  by  the  probe  striking  the  dead  bone, 
cannot  be  mistaken  by  the  educated  surgeon.  The  sound  is  of  a 
ringing  nature,  similar  to  that  produced  by  striking  it  ngaivst  a 


NECROSIS. 


279 


skeleton  bone.  Another  reliable  symptom  is  the  nature  of  the 
discharge.  In  a  pure  case  of  necrosis  it  is  composed  entirely  of 
laudable  pus;  if  there  be  anything  else  it  will  be  arterial  blood, 
which  has  escaped  from  the  forming  arteries  which  have  been 
lacerated  by  the  spiculae  of  bone,  or  the  probe  introduced  by  the 
surgeon. 

The  surgeon  has  to  determine,  by  the  symptoms,  not  only  that 
necrosis  exists,  but  also  the  extent,  and  the  stage  of  the  disease; 
whether  sequestration  is  nearly,  or  quite  consummated.  It  is  im- 
portant to  know  when  the  separation  is  finished,  because  until 
then  the  surgeon  cannot  materially  assist;  he  must  wait  until  na- 
ture has  done  her  work.  The  indications  by  which  this  shall  be 
determined  are  such  as  the  probe  alone  can  reveal.  In  most  cases 
there  will  be  two  or  more  openings,  which,  generally,  are  some  dis- 
tance apart,  perhaps  on  opposite  sides  of  the  limb.  By  passing  a 
probe  down  to  the  bone  it  may  be  at  once  felt  to  move,  revealing 
the  fact  of  its  separation.  Sometimes  a  second  probe,  introduced 
in  another  place,  and  then  the  two  manipulated  together,  will  re- 
veal the  fact  of  separation.  Possibly  the  sequestrum,  although 
quite  detached,  may  be  immovable;  this  will  result  from  the 
granulations  of  new  bone  becoming  so  intertwined  among  the 
spiculae  of  dead  bone,  that  the  fragment  is  very  firmly  fixed.  In 
such  cases  the  surgeon  would  wait  until  sufficient  timehad  elapsed 
to  remove  all  doubt. 

Treatment  of  Necrosis.— Already  it  has  been  seen  that  nature 
promptly  proceeds  to  detach  and  throw  off  the  dead  bone ;  and 
although  the  process  is  slow,  yet  in  the  healthy  subject  it  is  always 
successfully  accomplished.  While  this  work  is  being  done,  the 
surgeon  can  but  control  any  tendency  to  excessive  action,  and 
palliate  any  aggravating  symptoms  which  may  present  themselves; 
also  any  tendency  to  constitutional  disturbance;  or,  if  necessary, 
afford  support  to  the  strength.  No  interference  can  hasten  the 
process,  nor  is  it  allowable  to  remove  by  instrumer  ts  boue  which 
is  not  yet  detached ;  the  line  of  demarcation  is  uncertain,  and  the 
surgeon  might  remove  more  bone  than  is  doomed  to  perish ;  or  on 
the  other  hand,  he  might  not  remove  enough.  When,  however, 
sequestration  is  completed,  then  there  shouid  bo  no  delay  in  un- 
dertaking its  removal.  Heretofore,  nature  only  could  efficiently 
work,  now  the  surgeon  should  relieve  her  of  further  efforts  which 


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280 


PRINCIPLES    OP    SURGERY. 


I'  I 


she  will  strenuously  make  to  accomplish  what  lies  beyond  her 
legitimate  bound  of  duty.  In  external  necrosis  the  bone  may  be 
gradually  carried  toward  the  surface  of  the  body ;  but  it  is  slowly 
done,  while  by  the  surgeon  the  fragment  might  very  easily  be  ex- 
tracted. In  case  of  internal  and  incomplete  necrosis,  the  only 
way  by  which  the  unaided  powers  of  nature  may  expel  the  bone, 
is  by  the  open  sinuses  through  which  the  detritus  of  the  sequestrum 
can  be  carried  out,  after  it  has  disintegrated  by  chemical  action. 
When  the  fragment  is  large  the  time  will  be  distressingly  long 
before  the  extrusion  can  be  accomplished.  During  the  period  of 
separation  some  of  the  dead  bone  may  come  within  the  power  of 
the  absorbents;  but  subsequently  it  is  a  foreign  body,  beyond  the 
influence  of  animal  life.  And,  while  it  is  thus  quite,  or  altogether 
impossible  for  expulsion  to  be  effected  by  a  natural  process,  the 
constant  irritation  to  and  drain  made  upon  the  system  will  ex- 
pose it  to  great  danger.  These  are  cogent  reasons  why  no  delay 
should  be  made  in  removing  the  sequestrum. 

The  knife  need  not  be  always  used  to  remove  a  sequestrum. 
Very  often  the  fragment  may  be  extracted  by  forceps,  introduced 
through  the  sinuses.  This  may  be  happily  accomplished  when  the 
fragment  is  not  great  in  length.  Sometimes,  again,  the  dead  piece 
may  be  divided  by  small  pliers  introduced,  so  that  extraction  can 
be  done  by  piecemeal.  When  the  sequestrum  cannot  thus  be  re- 
moved, the  knife  will  have  to  be  resorted  to.  The  operation  now 
will  consist  in,  first,  making  an  incision  through  the  soft  parts  to 
the  bone ;  and  secondly,  through  any  bony  structure  that  may 
compass  the  sequestrum ;  and  lastly,  the  extraction  of  the  bone. 
The  division  of  the  soft  parts  must  be  sufficiently  extensive  to 
allow  the  second  step  to  be  taken  advantageously.  With  respect 
to  the  second  step — the  division  of  bone — it  is  important  to  re- 
member that  the  earlier  the  operation,  the  more  easily  will  the 
bone  be  divided,  as  it  is  more  soft.  After  sequestration,  any  sur- 
rounding bone,  whether  new  or  old,  will  become  even  harder  than 
natural  bone.  I  have  seen  not  a  few  cases — one  quite  lately,  my 
own  patient,  involving  the  femur — in  which  the  greatest  force  was 
requisite  to  divide  the  ivory-like  bone.  When  the  bone  is  quite 
soft,  it  may  be  divided  by  a  strong  knife ;  but  in  most  cases  the 
trephine  or  chisel,  and  often  both,  will  be  required.  The  first 
•perture  made  by  the  trephine  may  be  sufficient  to  allow  the  ex- 


NECROSIS. 


281 


traction  to  be  made ;  but  a  second  application  may  be  necessary, 
perhaps  a  short  distance  from  the  first,  and  then  the  intervening 
piece  of  osseous  substance  may  be  chiselled  out.  The  trephine 
should,  if  practicable,  be  applied  at  the  extremity  of  the  seques- 
trum. No  more  of  the  sound  bone  should  be  touched  than  is  ab- 
solutely necessary  to  make  way  for  extraction  of  the  dead  bone. 

The  sequestrum  being  removed,  the  operation  is  completed. 
The  bone  around  may  seem  to  be  unnatural  in  appearance,  per- 
haps softened ;  but  in  a  pure  case  of  necrosis,  it  will  be  found  that 
the  removal  of  dead  bone  will  rapidly  be  followed  by  a  perfect 
healing  of  the  bone.  There  must  be  no  gouging  as  in  caries ; 
even  manipulation  of  the  bright  red  tissue  should  not  be  prac- 
tised. Having  removed  the  dead  bone,  and  the  bleeding  having 
ceased,  it  will  be  well  to  place  a  piece  of  wetted  surgeon's  lint  in 
the  wound  of  the  soft  tissues,  to  prevent  adhesive  union.  The 
healing  must  go  on  primarily  at  the  bottom,  in  the  bone ;  and 
should  the  soft  parts  close  before  the  bone  has  healed,  the  forma- 
tion of  an  abscess  will  most  probably  result.  In  most  cases,  the 
recovery  is  quick  and  perfect. 

Softening  of  the  5owe.— There  are  several  causes  to  which  this 
may  be  due.  It  may  involve  a  part  or  the  whole  of  a  bone,  or  the 
whole  osseous  framework.  Certain  forms  of  softening  may  come  on 
at  certain  periods  of  life.  Rickets  is  a  disease  peculiar  to  child- 
hood.  MoUities  ossium  comes  on  in  adult  life,  occurring  more 
frequently  to  the  female.  Fragilitas  ossium  has  been  by  some 
regarded  as  a  form  of  softening ;  but  it  can  scarcely  be  so  con- 
sidered. 

MoUities  Ossium.—''  The  disease  which  appears  best  to  deserve 
a  separate  description,  under  the  name  of  mollities,  is  marked  by 
the  following  characteristics :  Several  bones  ar  usually  affected 
at  the  same  time.  The  portions  of  bone  attacked  are  uniformly 
softened,  throughout  the  whole  extent  of  the  disease.  The  dis- 
ease, h-wever,  does  not  in  all  cases  affect  either  the  whole  length 
or  the  whole  thickness  of  the  bone ;  and  if  the  specimen  be  ex- 
amined at  an  early  period,  the  outer  shell  is  often  found  to  retain 
its  natural  consistence.  When  the  whole  bone  is  affected,  it  can 
be  readily  bent,  and  resembles,  in  extreme  cases,  as  Dr.  Ormerod 
remarks,  rather  a  portion  of  fatty  matter  inclosed  in  a  case  of 
periosteum,  than  a  bone.     If  the  cancellous  tissue  (in  which  the 


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282 


PRINCIPLES    OP    SURGEBY. 


disease  appears  to  originate)  be  examined,  it  is  found  that  the  cells 
are  enlarged,  sometimes  to  such  an  extent  that  the  whole  bone  is 
expanded,  and  are  filled  with  a  peculiar  reddish  gelatiniform  mat- 
ter, in  which,  on  microscopical  examination,  much  fat  and  oil  can 
be  discovered,  together  with  blood-disks.  Besides  these  (which  are 
the  common  products  of  any  degenerative-  change),  certain  pecu- 
liar nucleolated  nuclear  bodies  have  been  described  by  Mr.  Dal- 
rymple.  Instances  of  bones  affected  with  mollities  ossium  do, 
however,  occur,  in  which  the  amount  of  fat  is  not  greatly  in- 
creased."    (Syst.  Surgery.) 

It  vviU  be  seen,  from  the  above,  that  true  mollities  ossium  is  a 
degeneration  of  the  bony  tissue.  We  have  seen  that  a  degree  of 
softening  attends  the  inflammatory  process,  and  that  a  long-con- 
tinued congestion,  with  effusion,  will  lead  to  absorption  of  the 
bony  fibres.  The  degeneration  called  mollities  ossium  may  be  a 
more  remote  result  of  the  inflammation. 

Causes. — All  forms  cf  softening  may  have  their  causes  divided 
into  general  or  local.  The  general  may  be  hereditary  or  acquird. 
Rickets,  a  disease  of  childhood,  is  unlike  mollities,  in  this  respect : 
that  it  much  resembles  scrofula,  and  is  hereditary.  The  true  mol- 
lities ossium,  although  coming  on  later  in  life,  is  most  frequently 
the  effect  of  a  constitutional  depranty,  which  may  have  been  im- 
mediately induced  by^a  local  cause.  Repeated  pregnancy  is  said 
to  be  an  exciting  cause. 

Result. — In  rickets,  under  suitable  treatment,  the  disease  may 
often  be  cured.  But  before  this  is  effected,  life-long  mischief  may 
have  been  done ;  the  bones,  being  more  or  less  bent,  may  have 
become  natural  in  conaistence  and  strength.  There  may  conse- 
quently result  deformity  of  the  limbs  and  of  the  spine,  or  a 
change  in  the  form  of  some  of  the  cavities  of  the  body.  In  the 
thorax,  the  heart  and  lungs  may  be  incommoded.  But  a  more 
common  evil  result  is  to  be  witnessed  in  the  pelvic  cavity  of  the 
female,  whereby  parturition  may  be  rendered  difficult  or  impossi- 
ble. True  mollities  ossium,  being  a  species  of  degeneration,  as 
well  as  coming  on  later  in  life,  is  much  less  amenable  to  treatment. 
The  bones  being  flexible,  motion  of  the  body  is  impaired,  or  per- 
haps impossible,  and  the  person  will  be  exposed  to  ail  the  evils  of 
the  system  attendant  upon  inactivity.  Exhaustion  is  likely  to 
ensue ;  and  in  most  cases,  though  not  always,  life  will  be  short- 


NECROSIS. 


283 


ened.  Both  in  rickets  and  mollities  ossium,  when  the  osseous 
fibres  are  made  brittle  by  change,  numerous  fractures  may  take 
place  m  the  bones,  from  muscular  action.  It  is  this  occasional 
symptom  which  has  caused  the  disease  to  be  confounded  with  fra- 
gilitas  ossium. 

Diagnosis.— Sohening  of  the  bone  bears  resemblance  to  atrophv 
and  cancer.  But  the  history  of  atrophy  will  be  found  different 
from  that  of  mollities  ossium.  And  also  with  that  of  cancer :  its 
origin  is  unlike  that  of  softening.  Moreover,  the  cancerous  dis- 
ease is  more  limited  in  its  nature. 

Treatment  of  rickets  is  essentially  the  same  as  that  prescribed 
in  scrofula.  (Vide  Treatment  of  Scrofula.)  Mollities  ossium,  un- 
fortunately,  is  not  often  cured.  Much  may  be  done  to  palliate 
the  helpless  condition— to  make  the  patient  comfortable.  By  po- 
sition, the  tendency  to  deformity  may  be  somewhat  counteracted. 
The  strength  must  be  supported. 

Hypertrophy  and  Induration  of  Bone.— In  these  diseases,  the 
bone  may  be  simply  denser  and  larger;  that  is,  the  osseous  fibres, 
although  normal,  are  more  numerous,  and  placed  closer  together; 
or  the  disease  may  be  due  to  a  deposition  of  fibrinous  matter  within 
the  interstices  of  the  bone,  which,  becoming  organized  and  incor- 
porated with  the  bony  fibres,  gives  to  the  bone  greater  consistence 
and  size.  The  cause  of  this  latter  condition  is  generally  inflam- 
mation, followed  by  exudation  of  lymph.  Continued  irritation 
may  be  sufl5cient  to  induce  unusual  growth. 

Treatment— "^hesQ  may  not  be  considered  pathological  condi- 
tions, which  will  give  rise  to  peculiar  symptoms ;  and  their  removal 
will  mainly  depend  upon  the  complete  cessation  of  the  cause,  and 
the  slow  but  often  effective  powers  of  nature.  The  administration 
of  iodide  of  potassium  may  possibly  hasten  the  return  of  the  bone 
to  health ;  also  the  local  application  of  iodine,  friction,  &c. 

Atrophy  of  Bone.— As  before  explained,  in  this  disease  there 
IS  not  any  diminution  in  volume  of  the  whole  bone.  The  atrophy 
18  in  the  individual  fibres  of  the  bone.  As  to  the  manner  in 
which  inflammation  leads  to  this  disease,  vide  Pathology  of  Inflam- 
mation. 

Causes.— May  be  enumerated  as  follows:  Inflammation;  in- 
jury ;  degeneration ;  old  age ;  failure  of  nutrition ;  long-continued 
confinement  from  illness;   obstruction  of  the  medullary  artery. 


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PRINCIPLES    OF    SURGERY. 


There  is  no  special  symptom  to  indicate  atrophy  of  bone,  nor  is 
there  any  particular  treatment.  (Syst.  Surgery.)  But  the  re- 
moval of  the  cause,  when  the  disease  is  suspected,  should  be 
attempted. 


CHAPTER    XXXV. 


Caries:  Pathology— Causes— Symptoms — Diagnosis— Prognosis — Treatment 
— General — Local — Operation — Tubercle  in  Bone. 

Caries. — Pathology. — This  is  a  disease  quite  distinct  from  ne- 
crosis, although  the  two  are  frequently  confounded.  To  have  a 
correct  idea  of  its  pathology,  the  student  must  understand  that 
the  morbid  state  arises  from  a  series  of  efforts  to  restore  bone 
which  had  become  impaired.  It  is  a  disease  of  the  healing  pro- 
cess, analogous  to  ulcers  of  the  soft  parts.  When,  from  any 
cause,  local  or  constitutional,  nature  fails  to  heal  a  lesion  in  the 
bone,  then  will  follow  the  disease  of  caries.  And  the  same  causes 
which  lead  to  unhealthy  ulcers  of  the  soft  parts  also  lead  to  this 
affection  of  the  bone.  Caries  may  follow  almost  any  disease  of 
the  bone.  Not  unfrequently  it  is  a  sequel  of  inflammation  of  the 
periosteum  and  bone.  It  may  coexist  with  or  follow  necrosis,  as 
well  as  softening  and  induration.  Remembering  the  analogy  be- 
tween caries  and  unhealthy  ulcers,  it  will  be  understood  there 
may  be  varieties.  As  to  ulcers  are  given  the  names  of  weak, 
scrofulous,  syphilitic,  &c.,  so  in  caries  the  same  names  may  be  ap- 
propriately applied.  But  while  caries  resembles  ulcers  generally, 
it  more  frequently  partakes  of  the  character  of  the  weak  and 
phagedenic.  In  the  majority  of  cases,  there  exists  too  much 
blood  in  the  part ;  this  blood  is  venous  in  character,  and  therefore 
wanting  in  the  necessary  elements  for  repair.  There  will  be  some 
arterial  blood  entering  the  part,  but  not  enough  to  supply  material 
for  healthy  healing.  The  fibrin,  imperfect  in  characf  <  r  and  vi- 
tality, goes  not  on  to  healthy  organization.  The  granulations, 
struggling  to  grow,  may  at  lain  to  a  certain  standard,  but  life  fails 
before  the  bone  is  at  all  mature.     The  material  by  which  repair 


CARIES. 


285 


nor  IS 


was  attempted  not  only  perishes,  but  it  constitutes  a  disintegrating 
substance,  which  will  corrode  the  base— the  living  bone — from 
which  the  granulations  had  sprung.  By  this  means,  the  disease, 
due  at  first  to  the  imperfect  character  of  the  fibrin,  gradually  ex- 
tends to  the  adjacent  bone,  which  primarily  had  been  unaffected. 
This  invasion,  by  the  disease,  of  new  territory,  will  be  a^.tended 
with  symptoms  of  inflammation  extending  to  the  soft  parts,  and 
by  the  formation  of  an  abscess  containing  imperfectly  elaborated 
pus,  admixed  with  venous  blood,  and  the  dSbris  of  reparative  ma- 
terial and  of  bone.  After  a  period  of  much  pain,  which  will  be 
terminated  by  a  discharge  of  the  abscess,  a  fresh  effort  will  be 
made  to  restore  the  bone,  and  perhaps  the  attempt  may  prove  suc- 
cessful ;  but  very  often  there  will  be  a  repetition  of  the  morbid 
steps,  the  effort  again  resulting  in  a  signal  failure,  and,  at  the 
same  time,  in  a  still  further  extension  of  the  disease.  Thus,  it 
will  be  seen,  caries  is  a  disease  of  the  healing  process  in  bone. 
These  fruitless  efforts  may  continue  for  weeks  and  months,  and 
even  years.  Now  and  then,  perhaps,  under  favorable  circum- 
stances, successful  restoration  may  be  for  a  time  made ;  but  this 
will  be  followed  by  a  return  of  the  disease,  and  continued  exten- 
sion of  the  morbid  process.  This  continued  local  irritation  and 
disease  cannot  but  impair  the  constitution,  perhaps  permanently. 
It  will  gradually  become  exhausted,  and  in  time,  if  no  relief  be 
obtained,  sink  under  the  protracted  irritation. 

This,  briefly,  is  the  pathology  of  caries — a  condition  quite  dif- 
ferent from  that  of  necrosis,  and  one,  also,  which  must  be  distin- 
guished from  softening  and  ulcerative  absorption,  whether  inter- 
stitial or  progressive.  At  the  same  time,  it  must  be  remembered 
that  two  often  coexist— that,  indeed,  caries  may  exist  with  almost 
every  other  disease  of  the  bone. 

(7aM«£!«.— These  have  already  been  referred  to.  There  are  two 
general  varieties :  constitutional  and  local.  The  former  are  such 
aa  affect  the  whole  system— the  blood.  These  may  have  been 
inherited  or  acquired.  The  more  important  are  scrofula,  syphilis, 
mercurial  poison,  and  debility  from  any  cause.  The  principal 
local  causes  are  injuries  and  inflammation.  When  there  is  a  pow- 
erful predisposing  cause,  only  a  slight  exciting  cause  is  necessary 
to  produce  the  morbid  action. 
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286 


PRINCIPLES    OP    8UEGBRY. 


the  disease,  and  will  be  modified  by  the  extent  to  which  the  dis- 
ease exists,  and  whether  any  other  affection  accompanies  it.  Af- 
ter a  bone  has  suffered  inflammation  or  an  injury,  should  there  be 
a  dull,  deep-seated  pain,  which  displays  a  tendency  to  extend 
along  the  bone,  there  is  reason  to  fear  that,  instead  of  the  healing 
process  being  consummated,  caries  is  commencing.  Accompany- 
ing the  first  step  in  the  disease  is  generally  a  diffused  swelling  of 
the  soft  parts,  not  very  great  in  any  one  part,  but  spread  over 
some  extent  of  surface.  At  first  the  integument  is  unchanged  in 
color ;  if  there  be  any  change,  it  is  an  unusual  paleness.  After  a 
while,  when  pus  begins  to  be  formed,  the  skin  will  present  a  livid 
red  appearance.  I  have  sometimes  seen  it  resemble,  very  closely, 
erysipelatous  inflammation.  Should  the  inflammation  be  very 
great,  of  course  the  pain  will  be  correspondingly  great.  The  pus, . 
instead  of  being  circumscribed,  will  be  diffused  in  the  subcutaneous 
tissue,  perhaps  even  beyond  the  neighborhood  of  the  diseased  bone. 
Ultimately,  the  pus  will  secure  an  opening  externally,  though 
the  process  of  pointing  is  very  slow,  as  in  diffused  suppuration. 
Often  there  are  several  collections  of  pus,  to  each  of  which  there 
will  be  an  opening,  and  from  which  there  will  be,  afterwards,  as 
many  sinuses,  through  which  the  diseased  bone  may  be  examined. 
The  discharge  from  these  sinuses  is  generally  offensive,  as  might 
be  expected,  from  the  fact  that  there  is  death  and  disintegration 
of  tissue.  The  pus  is  ill-conditioned,  thin,  and  admixed  with 
blood.  This  discharge,  coming  in  contact  with  the  surrounding 
tissue,  will  prove  highly  ichorous.  The  space  of  time  over  which 
these  symptoms  will  spread  themselves  varies  very  much,  but  fre- 
quently it  is  weeks  or  months. 

The  constitutional  symptoms  may  be  divided  into  those  which 
precede  the  local  disorder,  and  those  which  are  the  result  of  the 
local  (disease.  Of  the  former,  sufficient  has  already  been  said. 
Respecting  the  latter,  it  will  at  once  be  apparent,  when  it  is  re- 
membered that  the  disease  is  exhausting  and  prolonged,  that  vciy 
great  prostration  must  follow  this  disease  of  the  bone.  The  sys- 
tem, previously  below  par,  is  still  further  reduced,  and  very  often 
death  is  the  result. 

Diagnosis. — The  local  symptoms,  already  given,  are  to  a  great 
extent  characteristic ;  they  are  veiy  unlike  those  of  necrosis,  or 
other  diseasea  of  the  bone.    The  discharge  from  caries,  especially, 


CARIES. 


287 


is  quite  dissimilar  from  that  of  necrosis.     It  is,  however,  by  the 
probe  that  the  surgeon  can  the  most  fully  satisfy  himself  as  to  the 
nature  of  the  disease.     In  the  first  place,  the  mouth  of  the  sinus, 
in  caries,  is  different  from  that  seen  in  necrosis.     It  has  a  hard, 
bluish,  livid  border,  and  often  there  is  an  excrescence  sprouting 
up.     Upon  passing  the  probe  into  the  sinus,  it  will  not  meet  with 
any  solid  obstacle.     A  little  force  will  be  sufficient  to  pass  it 
through  the  fragile  and  soft  bony  granulations,  breaking  down 
the  delicate  vessels  which  are  engorged  with  venous  blood.    Hence 
it  is,  that  when  the  probe  is  thus  used,  there  will  be  a  free  venous 
hemorrhage.    The  probe,  when  it  reaches  the  bone,  is  not  arrested 
by  a  solid  substance,  as  the  sequestrum  of  necrosis,  nor  yet  as 
healthy  bone.     But  little  effort  is  required  to  penetrate  the  dis- 
eased structure.    The  probe  may  be  passed  in  different  directions, 
but  here  and  there  meeting  with  the  more  solid  bone.     This  con- 
dition is  so  characteristic  of  caries,  that  the  surgeon  cannot  easily 
be  mistaken.     The  diagnosis,  however,  may  be  embarrassed  by 
the  presence  of  necrosis  in  connection  with  caries ;  yet  even  then, 
the  history  of  the  case,  and  the  natiae  of  the  discharge,  with  the 
revelations  of  the  probe,  notwithstanding   the   sequestrum,  will 
enable  the  surgeon  to  arrive  at  a  correct  opinion. 

Prognosis.— Thia  will  depend  upon  the  condition  of  the  consti- 
tution ;  the  age  of  the  patient ;  his  position  and  circumstances  in 
life— that  is,  the  comforts  at  his  command ;  and  the  original  causes 
of  the  disease.  The  coexistence  of  two  or  more  unfavorable  con- 
ditions will  naturally  aggravate  the  case,  and  render  recovery 
less  hopeful.  When  the  constitutional  cause  is  scrofula,  the  prog- 
nosis is  more  doubtful.  Also,  when  the  disease  is  located  near  a 
joint,  there  is  danger  of  complication.  When  of  long  standing, 
the  disease  will,  as  a  general  thing,  prove  less  tractable,  from  the 
fact  that  the  system  has  become  depraved  and  exhausted.  Again, 
when  the  diseased  bone  is  naturally  spongy,  and  when  the  disease 
mvolves  several  small  bones  which  are  placed  closely  together,  as 
the  carpal  and  tarsal  bones,  the  result  will  be  more  doubtful. 

Treat7nent.— In  all  affections  of  the  bone,  care  should  be  taken 
to  prevent  this  disease,  more  especially  when  there  exists  any 
predisposing  cause.  The  requisites  for  the  successful  healing  of 
bono  must,  if  possible,  be  secured;  for  it  must  not  be  forgotten 
that  caries  is  a  disease  of  the  healing  process.     The  treatment 


Ih  i 


288 


PRINCIPLES    OP    SURQERT. 


naturally  divides  itself  into  that  which  is  directed  to  the  constitu- 
tion, and  that  which  is  applied  to  the  part.  As  in  other  affections, 
the  stage  of  the  disease  as  well  as  the  intensity,  will  modify  the 
treatment.  Speaking  generally,  the  constitutional  treatment  will 
consist  of  such  measures  as  will  correct  existing  evils  in  the  sys- 
tem, and  as  will  aid  in  the  formation  of  healthy  blood  for  the  work 
of  repair  in  the  bone. 

In  treating  locally,  the  aim  should  be  to  restore  and* maintain 
the  pait  in  a  state  as  natural  as  may  be  possible.  When  inflam- 
mation arises  it  will  have  special  attention,  and  when  pus  is  form- 
ing, a  free  exit  for  it  must  be  secured.  Emollients  will,  at  times, 
be  useful,  but  they  must  not  be  continued  too  long,  as  they  will 
increase  the  passive  congestion.  One  matter  of  great  importance 
is  to  keep  the  part  perfectly  clean.  The  constant  discharge  may 
at  times  render  this  difficult.  The  dressing  ought  to  be  light  and 
frequently  renewed.  The  access  of  air  to  the  part,  so  long  re- 
garded as  dangerous,  can  do  no  harm,  and  often  it  will  act  as  a 
healthy  stimulant.  And  if  *he  air  could  be,  by  any  possibility,  a 
source  of  evil,  it  could  not  prove  so  injurious  as  the  contact  of 
bandages  saturated  with  the  unhealthy  discharge. 

The  pus  mixed  with  the  debris  is  often  highly  irritating,  and  if 
allowed  to  remain  upon  the  surrounding  integument,  cannot  but 
produce  a  greater  amount  of  inflammation.  The  sores  should  be 
dressed  at  least  once  a  day,  and  the  skin  around  be  thoroughly 
washed  with  castile  soap  and  water,  and  then  made  quite  dry. 
The  beneficial  effect  of  this  alone  is  often  very  great.  Indeed,  in 
a  large  number  of  cases,  cleanliness,  rest,  and  position,  will  be 
sufficient  local  treatment.  Stimulating  injections  are  sometimes 
used,  with  the  object  of  promoting  healthy  granulations.  Iodine 
is  a  great  favorite.  After  a  good  deal  of  experience  in  these 
cases,  I  must  say  that  these  injections  rarely  accomplish  any 
permanent  good. 

Not  unfrequently,  although  the  general  health  may  have  much 
improved  under  constitutional  treatment,  and  many  local  measures 
have  been  usefully  employed,  yet  the  disease  does  not  show  any 
disposition  to  abate.  In  some  respects  there  may  be  an  improve- 
ment, yet  on  the  whole  there  are  no  signs  of  a  cure.  This  will 
be  in  consequence  of  the  very  extensive  mass  of  disease,  so  great 
that  physiological  action  cannot  seemingly  supersede  the  patho- 


"!'  i 


CARIES. 


289 


logical,  and  permanent  repair  is  not  effected.  In  such  cases  to 
wait,  IS  to  unnecessarily  expose  the  patient  to  pain  and  danger. 
The  only  course  to  pursue  is  to  remove  the  diseased  structure  com- 
pletely. Attempts  are  sometimes  made  to  destroy  t^e  carious 
bone  by  the  use  of  caustics;  but  they  will  act  very  uncertainly 
not  reaching  every  part  affected,  while  destroying  the  healthy 
texture.     The  better  way  is  to  employ  the  knife  and  the  gouge. 

Operation.— The  operation,  as  in  necrosis,  consists  in  dividing 
the  soft  structures  which  overlie  the  diseased  bone  to  a  sufficient 
extent,  and  then  in  removing  every  portion  of  the  carious  bone. 

There  is  this  important  difference  between  the  operation  in  ca- 
nes and  that  for  necrosis.     In  the  latter  the  principal  difficulty 
IS  to  so  expose  the  dead  bone  that  its  extraction  may  be  effected 
the  removal  itself  being  easy  enough.     And  when  the  sequestrum 
IS  taken  away  the  operation  is  completed.    Not  so  in  caries.    The 
diseased  bone  can  always  be  easily  enough  reached,  but  not  quickly 
removed.     There  is  no  regular  line  of  demarcation  between  the 
diseased  mass  and  the  sound  bone;  and  while  it  is  necessary  to 
take  away  all  of  the  former,  it  is  very  desirable  not  to  injure  the 
latter.     The  large  quantity  of  venous  blood  with  which  the  part 
18  engorged,  gives  rise  to  copious  hemorrhage,  and  this  will  render 
the  operation  tedious  at  least,  and  often  will  prevent  that  ocular 
exammation  which  is  desirable.     As  a  general  thing,  the  surgeon 
must  trust  to  the  sense  of  touch,  rather  than  to  sight,  and  the 
educated  finger  is  a  good  guide.     It  will  not  be  difficult  to  dis- 
tinguish the  sound  bone  from  the  unsound.     The  removal  of  the 
soft  and  carious  bone  must  be  complete,  otherwise  the  process  of 
repair  might  still  fail.     Generally  the  gouge  will  suffice  to  cut 
away  the  disease  m  its  various  directions;    but  occasionally  the 
saw  may  be  advantageously  employed,  excising  a  portion  of  the 
whole  shatt,  or  a  part  of  the  body  of  the  bone.     A  saw  is  always 
preferable  to  pliers,  because  the  latter,  before  dividing  the  osseous 
fabres  will  crush  and  thus  injure  their  vitality,  and  thereby  subse- 
quent  healing  is  seriously  endangered. 

The  carious  bone  completely  removed,  the  cavity  will  be  filled 
with  oiled  lint,  that  the  process  of  healing  may  begin  at  the  hot- 
torn  Cones  sometin^es  attacks  bones  which  are  beyond  the  reach 
ot  the  knife  and  gouge,  as  the  vertebrce.    In  such  cases  the  powers 

ot  nature  must  be  sunnortod.  tniafm^  tn  b^r  ti-'-'J '■ 1 

19 


!    '  1  ;-. 


Ul 


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1      i  1  i  n'l} 

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I  J 


290 


PRINCIPLES    OP    SURGERY. 


her  energies  aright.  Rest  of  body  and  mind  will  be  diligently 
secured.  And  counter-irritation,  perhaps  in  the  form  of  a  moxa, 
will  often,  by  diverting  nature,  enable  restoration  to  take  place. 
The  kind  qf  moxa  which  I  have  found  serviceable,  is  one  of  gum 
camphor  shaped  to  the  form  of  a  cone.  This,  placed  over  the 
seat  of  disease,  is  surrounded  by  a  piece  of  cotton,  and  then  fired. 
The  result  is  a  circumscribed  eschar,  and  in  a  day  or  two  an  issue. 
By  placing  peas  in  the  space  the  issue  will  be  continued. 

Tubercle  in  Bone. — The  tubercular  matter  may  be  diffused  in 
the  cancelli,  the  lacunae,  and  in  the  canaliculi,  or  it  may  be  col- 
lected in  the  form  of  a  distinct  tubercle.  It  is  very  likely  to  re- 
sult from  irritation,  inflammation,  or  injuries.  The  presence  of 
the  morbid  element  in  the  bone  is  very  likely  to  give  rise  to  a 
low  form  of  inflammation,  and  subsequently  to  caries.  The  dis- 
ease is  commonly  seen  in  the  tibia,  about  the  knee-joint,  and  in 
the  bones  of  the  cranium.  Not  a  few  cases  have  come  under  my 
notice  among  scrofulous  children,  where  a  fall  upon  the  bone  had 
been  followed  by  deposition  of  tubercle.  This  would  lead  to  the 
formation  of  an  abscess,  and  subsequently  a  carious  state,  which 
would  prove  difiicult  of  cure.  As  to  treatment,  it  is  unnecessary 
to  repeat  what  has  been  said  in  connection  with  the  general  prin- 
ciples of  scrofula. 

For  Tumors  of  Bone,  Cancer  of  jrfone,  and  Aneurism  of  Bone, 
see  those  diseases  respectively. 


CHAPTER    XXXVI. 

Fractures  :  Deflnition— Causes— Bones  most  liable— Classification— "Variety 
of  Displacement— Causes— Symptoms  of  Fracture— Diagnosis— Mode  of 
Examining — Prognosis. 


This  last  surgical  affection  of  the  bones  which  has  to  be  con- 
sidered is  one  of  common  occurrence,  and  is  naturally  very  inte- 
resting. The  office  of  the  surgeon,  when  called  to  a  case  of 
fracture,  is  to  restore  the  broken  bone  to  its  natural  position,  and 
avert  deformity.     A  slight  deviation  of  the  fragments  in  their 


>  an  issue. 


FRACTURES. 


291 


natural  relationship  will  mar  the  symmetry  of  the  hody,  and,  to  a 
greater  or  less  extent,  incapacitate  the  part  for  its  natural  function  • 
and  the  surgeon  is  expected  to  so  arrange  the  fragments  that  no 
deformity  shall  exist  after  union.  Any  neglect  or  ignorance  on  his 
part  will  likely  lead  to  failure  in  securing  the  desired  end,  and,  at 
the  same  time,  to  his  disgrace.  The  grave  may  conceal  the  mis- 
takes of  the  physician,  and  also  of  the  surgeon,  in  most  other 
affections,  when  those  mistakes  lead  to  death ;  but  an  error  in  the 
treatment  of  fracture,  and  also  of  dislocation,  will  not  destroy 
life,  but  remain  living  witnesses  against  the  practitioner.  Cases 
will  often  enough  occur,  in  which  deformity  will  ensue  in  spite  of 
the  best  treatment,  without  the  number  being  added  to  in  conse- 
quence of  culpable  ignorance  or  neglect.  Inasmuch,  then,  as  the 
injury  is  of  frequent  occurrence,  and  the  issue  one  of  great  im- 
portance—not alone  to  the  patient,  but  quite  as  much  to  the  sur- 
geon's character— it  is  necessary  that  the  student  should  give  to 
the  subject  the  most  earnest  attention. 

It  is  scarcely  necessary  to  define  the  term  fracture ;  it  is  well 
understood  to  mean  a  violent  division  of  bone  into  parts.  The 
bone  is  not  cut;  it  is  broken  by  violence,  directly  or  indirectly 
applied.  "^ 

Causes.—M^j  be  divided  into  prediBposing  and  immediate. 
The  predisposing  causes  may,  again,  be  divided  into  local  and 

general. 

Local  Predisposing  Cames.— First,  the  dtuation  of  a  bone  may 
render  it  liable  to  fracture,  from  its  being  exposed  to  injury.  And 
the /tmcfww,  also,  may  expose  it  to  that  accident;  for  instance 
the  radius,  from  its  relation  and  function  at  the  wrist  joint,  is  a 
bone  frequently  broken ;  also,  the  clavicle,  whose  function  it  is  to 
retain  the  arm  in  the  most  useful  position,  is  subject  to  injury 
when  the  body  falls  upon  any  part  of  that  extremity.  Local  in- 
flammation, and  other  diseases,  will  often  so  weaken  the  bone  as  to 
favor  breaking  of  the  osseous  fibres. 

General  Predisposing  Oauses.—A  large  number  may  be  men- 
tioned.  Peculiarity  of  diathesis,  as  syphilis,  mollities  ossium,  fra- 
gihtas  ossium,  rickets,  gout,  scrofula,  cancer,  scurvy,  mercurial 
poison-indeed,  any  exhausting  or  low  disease.  And  old  age  is  a 
predisposing  cause.  The  fact  that  the  bones  become  more  and 
more  brittle  as  age  advances,  after  maturity,  makes  it  intelligible 


'l'<i.: 


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292 


PRINCIPLES    OP    SURGERY. 


i    If 


why  this  surgical  affection  is  most  likely  to  occur  in  the  aged. 
Not  only  is  the  bone  more  brittle  in  those  advanced  in  life,  but 
such  persons,  also,  do  not  possess  that  muscular  power  which  is 
often  called  into  requisition  to  save  one  from  falling.  Fractures 
occur  more  frequently  in  winter  than  in  summer ;  not  because  the 
bones  are  then  more  brittle,  although  that  has  before  now  been 
taught ;  but  because  of  the  benumbing  influence  of  the  cold,  espe- 
cially upon  the  old.  Then,  at  that  season  the  earth  is  hard  from 
frost  and  ice,  and  every  one  is  more  likely  to  lose  his  equilibrium, 
and  fall  upon  the  hard,  resisting  ground.  The  male  is  more  sub- 
ject to  fracture  than  the  female,  from  the  fact  that  he  is  more 
exposed  to  injuries  of  every  kind.  In  old  persons,  however, 
fractures  are  said  to  occur  more  frequently  in  the  female.  Several 
of  the  foregoing  local  and  general  predisposing  causes  may  co- 
exist. 

Immediate  Causes. — Of  these  there  are  two :  muscular  action 
and  external  violence. 

The  bones  more  frequently  broken  by  muscular  action  are  the 
patella,  os  ealeis,  and  olecranon.  Others  are,  however,  sometimes 
broken.  On  this  subject,  Hamilton,  in  his  most  excellent  work, 
writes  as  follows :  "  These  accidents  imply  generally  some  con- 
ditions of  the  bones  themselves  which  predispose  them  to  fracture ; 
but  I  have  seen  one  example  of  a  fracture  of  the  shaft  of  the  fe- 
mur, in  a  large  and  perfectly  healthy  man,  occasioned  by  a  twist 
of  the  leg  in  rolling  tenpins.  I  have  also  known  the  tibia  and 
patella  to  break,  from  natural  muscular  action,  in  persons  of  un- 
common vigor.  Fractures  sometimes  occur  in  the  violent  contor- 
tions of  the  muscles  during  convulsions,  and  where  no  abnormal 
condition  of  the  bones  could  be  assumed  to  exist.  Parker,  of 
New  York,  relates  a  case  of  fracture  of  the  humerus,  in  a  negro 
preacher,  which  occurred  in  the  act  of  gesticulation ;  also,  a  frac- 
ture of  the  clavicle,  occasioned  by  striking  a  dog  with  a  whip ;  in 
another  case,  the  humerus  was  broken  in  attempting  to  throw  a 
peach ;  but  the  most  singular  case  of  all  was  a  fracture  of  the  hu- 
merus, caused  by  an  effort  to  extract  a  tooth. 

"  Nearly  all  of  the  cases  of  fractures  occasioned  by  muscular 
contraction,  seen  by  me,  were  transverse,  or  nearly  so,  indicating, 
perhaps,  also,  the  existence  of  some  unusual  fragility." 

The  external  violence  may  be  direct  or  indirect.    For  example, 


FRACTURES. 


293 


the  clavicle  may  be  fractured  from  a  blow  received  immediately 
over  the  bone,  or  it  may  be  from  a  fall  upon  some  part  of  the 
arm,  the  force  being  transmitted  to  the  part  most  easily  broken. 

Bones  mo%t  Uable.^The  bones  of  the  body  moat  liable  to  frac- 
ture are  the  long  bones.  The  bones  of  the  leg  support  the  body, 
and  those  of  the  arms  are  constantly  called  into  use  as  levers,  and 
so  both  are  exposed  to  injury.  Moreover,  the  great  muscular 
power  by  which  these  limbs  are  moved  must  necessarily  jeopardize 
the  bones  upon  which  they  act.  On  the  contrary,  the  broad,  flat 
bones,  from  their  situation  and  function,  are  comparatively  safe 
from  injury.  To  this  general  rule,  however,  the  bones  of  the  era- 
mum  must  be  excepted;  these,  for  obvious  reasons,  are  very 
liable  to  fracture.  Short  bones  enjoy  immunity  from  this  acci- 
dent. 

Fracture  of  long  bones  may  take  place  at  any  point,  but  it  is 
most  frequent  at  or  about  the  middle.  The  reason  of  this  is  ob- 
vious.  The  bone  will  be  bent  until  it  breaks,  and,  like  a  rush, 
will  yield  first  in  the  middle,  unless  some  other  part  be  more 
weak.  But  when  the  violence  is  directly  applied,  the  fracture  will 
generally  be  at  the  place  struck. 

Olassification  of  Fractures.— I  shall  give  several  divisions,  as 
stated  by  different  writers,  because  it  will  afford  instruction  in  the 
important  principles  under  consideration. 

The  first  is  into  complete  and  incomplete.     That  is,  the  bone 
may  be  entirely  divided,  or  it  may  be  bent  almost  to  breaking :  as 
the  tough  sapling  is  sometimes  bent  until  some  of  the  fibres  are 
divided,  although  the  trunk  is  not  completely  severed.    When  any 
of  the  osseous  fibres  remain  undivided,  it  is  designated  incomplete 
iracture.    This  kind  is  more  common  in  the  young,  when  the  bone 
possesses  less  of  the  harder  elements  of  bone.     Recently,  I  have 
had  under  my  care  an  incomplete  fracture  of  the  radius,  with  com- 
plete fracture  of  the  ulna,  about  two  inches  from  the  wrist  joint. 
The  lad  was  in  his  eighth  year.     Playing  in  a  barn,  he  fell  to  the 
ground,  and  struck  upon  the  hand.     It  was  the  most  perfect  case 
of  incomplete  fracture,  and  was,  with  comparative  ease,  bent  back 
to  the  original  form. 

A  second  division  is  based  upon  the  direction  of  the  fracture 
According  to  this  division,  there  is  the  transverse,  the  oblique, 
and  the  longitudinal  fracture.     Bones  which  are  brittle  are  gene- 


i»S?' 


7  V ;  ill 


ill 


I    U  IMI  I 


294 


PRINCIPLES    OP    SURGERY. 


1     f 


rally  broken  transversely ;  hence  the  kind  of  fracture,  in  old  per- 
sons, known  as  the  pipe-stem  fracture.  Longitudinal  fracture  is 
generally  due  to  direct  violence,  in  connection  with  which  there  is 
generally  comminution  of  the  bone. 

A  third  diviaion  is  baaed  upon  the  appearance  which  the  frac- 
ture presents.  Thus,  we  have  fissures,  stellated  fracture,  indented 
fracture,  &c. 

A  fourth  diviaion  is  baaed  upon  the  character  of  the  diaplaee- 
ment.  In  the  first  place,  there  may  be  no  displacement,  although 
the  fracture  be  complete.  When  displacement  attends,  it  may  be 
longitudinal;  that  is,  the  ends  of  the  fragments  will  override,  and 
the  limb  be  shortened.  This  form  of  displacement  is  more  gene- 
rally seen  when  the  fracture  is  oblique.  It  may,  however,  be  due 
to  considerable  force,  by  which  the  displacement  is  produced. 
Again,  the  displacement  may  be  lateral;  the  broken  ends  do  not 
come  fairly  together,  one  being  to  one  side  of  the  other.  Rotary 
diaplacement  is  when  one  fragment  is  turned  on  its  own  axis ;  the 
displacement  is  in  the  circumference.  Angular  diaplacement — 
when  the  two  fragments  so  come  together  as  to  form  an  angle, 
more  or  less.  Impacted  fracture  is  where  the  two  fragments  ai^ 
driven  into  each  other.  The  force  which  produced  the  fracture, 
or  perhaps  some  other  power,  forces  the  fragments  together — the 
osseous  fibres  of  one  among  those  of  the  other.  Sometimes  the 
union  thus  effected  is  very  firm.  The  relationship  of  the  pieces 
may  be  natural,  but  very  often  there  is  some  displacement.  The 
bones  in  which  impaction  most  frequently  occurs  are  the  femur 
and  the  humerus,  at  their  necks. 

In  connection  with  this  subject,  it  is  necessary  to  state  that  the 
cauaea  of  the  aeveral  forma  of  diaplacement  are  capable  of  a  useful 
classification.  Thus,  there  is,  first^  external  violence,  which  vio- 
lence may  be  the  force  which  produced  the  fracture,  or  it  may  be 
some  other  subsequent  violence,  direct  or  indirect.  Or  the  dis- 
placement may  be  due  to  the  weight  of  the  limb  or  of  the  body  in 
falling,  after  the  injury  is  received.  Also,  during  the  process  of 
removal  of  the  patient,  the  weight  of  the  limb,  with  the  muscular 
contraction,  may  produce  displacement.  Muscular  contraction  is 
ulone  a  frequent  cause  of  displacement.  The  muscles  attached  to 
the  fragments  are  irritated,  and,  in  Consequence,  contract  spasmo- 
dically ;  and  the  lever  being  broken,  there  can  be  no  harmonious 


FRACTURES. 


295 


action  of  the  whole— instead  of  which,  the  lower  piece  will  be 
often  brought  into  a  variety  of  abnormal  positions.  It  is  neces- 
sary, however,  to  notice  here,  that  sometimes  the  muscles  are  be- 
numbed and  paralyzed,  so  that,  from  their  action,  displacement  is 
impossible. 

Another  division  of  fracture  is  into  simple,  complicated,  com- 
pound, and  comminuted.  By  simple  fracture  is  understood  a 
breakage  of  the  bone  with  no  other  lesion,  and  followed  by  no 
subsequent  inflammation.  By  complicated  fracture  is  meant  a 
condition  in  which  there  is  something  more  than  a  fracture.  The 
complication  may  be  local  or  constitutional.  Among  the  local 
complications  are  severe  bruising,  wounds,  injuries  to  nerves  and 
vessels.  Constitutional  complications  are  such  as  may  tend  to 
excessive  exhaustion,  or  inflammation,  or  in  any  way  to  interfere 
with  the  process  of  repair.  A  compound  fracture  is  a  complica- 
tion ;  but,  because  of  its  comparative  frequent  occurrence,  as  well 
as  importance,  it  receives  a  special  notice.  It  consists  of  a  wound 
with  the  fracture,  by  which  the  fractured  ends  communicate  with 
the  air.  A  wound  with  a  fracture  simply  does  not  constitute  what 
is  understood  by  the  term  compound.  This  wound  of  the  soft 
parts  may  have  been  produced  by  the  object  which  came  in  con- 
tact with  the  body,  when  producing  the  fracture,  or  it  may  have 
been  caused  by  the  falling  of  the  limb  or  the  body,  so  as  to  force 
a  broken  end  through  the  soft  parts.  Subsequent  inflammation, 
and  the  formation  of  an  abscess,  may  open  a  passage  to  the  broken 
bone,  and  thereby  beget  a  compound  fracture. 

The  term  comminuted  fracture  is  applied  when  there  are  two  or 
more  fractures  of  the  bone.  The  idea  generally  associated  with 
the  term  is  a  breaking  of  the  bone  in  several  small  pieces,  by  some 
direct  violence,  perhaps  actual  crushing  of  the  bone. 

Symptoms  of  Fracture. —There  are  a  variety  of  symptoms,  some 
of  which,  being  physical  signs,  are  excellent  diagnostic  marks, 
while  others  are  only  important  when  taken  in  connection  with 
the  former.  Pain  is  a  very  common  symptom,  and  is  very  severe ; 
yet  similar  pain  may  be  the  result  of  other  injuries  and  diseases. 
Pain,  in  connection  with  fracture,  is  generally  due  to  the  spas- 
modic twitching  of  the  muscles,  by  which  action  the  sharp  broken 
fragments  are  forced  into  the  soft  tissues  or  nerve  trunks.  There 
are  often  exacerbations  of  the  pain.    In  those  cases  where  the 


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296 


PRINCIPLES    OF    SURGERY. 


{1 


muscles  are  paralyzed,  there  will,  of  course,  be  an  entire  absence 
of  pain. 

Loss  of  voluntary  motion  is  another  symptom.  The  bones  are 
moved  in  a  state  of  nature  on  the  principle  of  the  lever ;  when 
therefore,  the  bone  is  broken,  effectual  motion  of  the  limb  cannot 
be  made  ;  the  patient  has  no  control  over  it.  But  there  may  be 
loss  of  voluntary  motion  from  other  causes.  The  nerve  may  be 
injured  by  a  bruise  or  a  wound;  consequently,  simply  loss  of 
power  to  move  the  limb  does  not  always  indicate  fracture.  Swell- 
ing and  also  ecchymosis  may  be  given  as  local  symptoms,  but  they, 
like  the  forementioned,  exist  often  in  connection  with  other 
injuries. 

Unless  the  fracture  be  a  very  simple  one,  there  will  be  some 
constitutional  disturbance.  But  the  general  symptoms,  like  the 
above-mentioned  local  ones,  are  not  reliable  diagnostic  marks, 
inasmuch  as  an  equal  amount  of  general  derangement  may  result 
from  other  injuries.  The  effect  upon  the  constitution  need  not  be 
of  long  duration  ;  for,  as  soon  as  repair  commences,  there  ought 
to  be  a  physiological  condition  of  the  whole  system. 

The  physical  symptoms  of  fracture,  to  which  the  surgeon  can 
in  the  main  trust,  as  diagnostic  features,  arc  palpable  to  any  be- 
holder. The  one  which  most  frequently  presents  itself  is  a  change 
in  the  natural  form  of  the  limb.  Displacement  of  the  fragments 
cannot  exist  without  deformity,  and  the  nature  of  the  deformity 
will  depend  upon  the  form  of  displacement.  Consequently,  the 
surgeon  will  often  be  able  to  distinguish  the  form  of  displacement 
by  the  deformity  which  presents  itself.  The  degree  of  deformity 
will  depend  upon  the  direction  of  the  fracture,  and  the  number 
and  power  of  the  muscles  attached  to  the  bone  which  is  broken. 
Another  trustworthy  symptom  is  the  unnatural  mobility  at  the  seat 
of  fracture.  The  slightest  contraction  of  the  muscles,  or  a  moving 
of  the  limb  will  be,  in  most  cases,  sufficient  to  cause  motion  at  a 
point  where,  in  a  sound  limb,  it  is  impossible  to  have  it.  Change 
in  the  length  of  the  limb,  is  commonly  specified  as  a  symptom ;  it 
is,  however,  but  a  change  in  the  form  of  the  limb.  Being  a  com- 
mon symptom,  it  requires  special  notice.  The  action  of  the 
muscles  which  are  attached  to  the  arms  and  logs  mainly  draw  them 
toward  the  body ;  therefore,  when  one  of  the  bones  is  broken,  the 
lower  fragment  alone  will  be  acted  upon,  thereby  shortening  the 


FRACTURES. 


29? 


absence        ■        limb.     In  oblique  fracture  the  shortening  is  generally  greater  than 
m  the  transverse. 

The  next  symptom  to  be  noticed  is  crepitus.     This,  when  pre- 
sent, is  a  valuable  diagnostic  symptom.     It  is  a  sound  or  sensa- 
tion imparted  to  the  hand  of  the  surgeon,  manipulating,  and  is 
caused  by  the  broken  ends,  rubbing  together.     It  cannot,  however, 
always  be  detected ;  not  so  frequently,  indeed,  as  is  generally 
supposed.     It  will  now  and  then  happen,  that  the  fractured  ends 
cannot  be  brought  together  so  as  to  produce  the  crepitus,  and  it 
may  be  here  stated  that  the  surgeon  should  never  endeavor  to 
make  the  crepitus.    More  especially,  when  the  nature  of  the  injury 
IS  palpable  without  the  aid  of  this  symptom.     The  violent  and  un- 
natural  contraction  of  the  muscles  often  preclude  the  possibility  of 
approximating  the  broken  ends ;  and  the  efforts  of  the  surgeon  to 
do  so  will  only  increase  the  difficulty.     In  fracture  of  the  patella 
and  olecranon,  for  instance,  the  fragments  are  so  drawn  apart  by 
the  muscles,  that  crepitus  becomes  impossible.     Again,  when  there 
is  impaction  of  the  fragments,  or  an  incomplete  fracture,  crepitus 
will  be  absent.     Also,  "crepitus  may  be  distinct  enough;  but  in 
such  a  direction  as  to  mislead,  on  account  of  the  relation  of  other 
bones  to  the  one  broken."  (Hamilton.) 

On  the  other  hand,  there  is  sometimes  a  sound  like  unto  cre- 
pitus, which  is  produced  by  fibrin  or  synovial  fluid,  which  has  oc- 
cupied the  cellular  tissue,  and  is  now  in  a  somewhat  inspissated 
state.  To  create  the  crackling  sound,  pressure,  or  manipulation 
IP  sufficient.  But  this  will  never  be  heard  until  after  a  few  days  • 
whereas,  true  crepitus  is  more  distinct,  other  things  being  equal! 
immediately  after  the  fracture.  Indeed,  very  often  the  crepitus 
will  entirely  cease  after  a  few  days,  that  is,  when  the  broken  ends 
become  covered  with  reparative  material. 

magnom.—1\iG  affections  from  which  fractures  have  to  be  dis- 
tinguished  are  luxations,  bent  bones,  sprains,  also  from  an  incom- 
plete fracture.  In  speaking  of  the  several  symptoms,  it  was 
deemed  expedient  to  point  out  wherein  each  was  important  as  a 
diagnostic  mark,  as  well  as  in  what  way  they  might  be  deceptive. 
In  the  majority  of  cases  there  will  be  no  difficulty  in  discovering 
the  existence  of  the  fracture,  when  it  has  occurred  at  or  about 
the  middle  of  a  long  bone.     But,  when  the  fracture  is  near  a  joint, 

■      It  may  require  some  diMcHminftfinn  ♦«  /)/>fx^»»  :*      rru_  j- «. 

^=  -        -  • s '— uvvvt,v  it.      Auu  uiagnosis  oi 


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298 


PRINCIPLES    OF    SURGERY. 


fracture  from  dislocation  will  be  more  easily  understood  and  re- 
membered after  the  principles  of  dislocation  have  been  discussed 
(to  which  please  refer). 

In  the  young,  as  well  as  from  certain  diseases,  the  bone  may 
bend  very  near  to  the  joint,  and  covered  up  by  the  muscles  and 
other  tissues,  there  may  be  presented  an  appearance  closely  re- 
sembling that  of  fracture.  The  history  of  the  case,  and  a  very 
little  manipulation,  will  enable  the  .^surgeon  to  detect  the  one  from 
the  other.  Sprains  are  sometimes  mistaken  for  fracture,  and  vice 
versa.  At  first,  before  swelling  has  taken  place,  there  can  be  no 
difficulty  in  the  diagnosis ;  but  very  often  the  surgeon  is  only 
called  in  when  the  swelling  and  pain  have  become  severe.  Very 
often  the  swelling  arising  from  the  sprain  gives  the  part  the 
appearance  of  displacement  of  bone,  such  as  attend  fracture,  or 
dislocation.  It  will  be  remembered  that  those  tissues  which  are 
yielding,  readily  become  swollen,  and  that  it  is  contrariwise  with 
those  which  are  unyielding ;  hence  the  fact  that  the  swelling  about 
the  joint  is  not  uniform,  and  consequently,  the  appearance  of  dis- 
placement. Incomplete  fracture  may,  at  first,  be  mistaken,  in 
consequence  of  the  evident  deformity,  while  at  the  same  time  there 
is  no  unnatural  mobility.  But  careful  manipulation,  by  the  aid  of 
other  signs,  will  be  sufficient  to  diagnose  the  case.  A  bone,  thus 
half  broken,  can  often  be  very  quickly  straightened.  And  the 
surgeon,  before  doing  so,  should  point  out  its  character  to  the 
patient  and  friends,  otherwise,  it  may  come  to  pass  that  they  will 
doubt  if  a  broken  bone  can  so  readily  recover. 

In  proceeding  to  examine  a  broken  limb,  the  surgeon  ought  to 
be  quite  possessed — free  from  trepidation,  and  in  no  hurry.  He 
should  constantly  bear  in  mind  the  important  principle,  that  no 
more  manipulation  is  justifiable  than  is  absolutely  necessary  to 
determine  the  nature  of  the  injury,  and  to  form  correct  views  upon 
which  to  base  the  treatment.  The  old  rude  way  of  ruthlessly 
seizing  the  limb  as  if  it  were  guilty  of  misdemeanor,  was  but  a 
relic  of  barbarian  practice,  and  is  now,  fortunately,  almost  obso- 
lete. On  this  subject,  I  will  quote  from  the  pages  of  Hamilton. 
But  while  I  do  so,  I  must,  in  justice  to  myself,  say,  that  two  years 
before  I  had  enjoyed  the  great  satisfaction  of  reading  his  work,  I 
taught  the  same  principles,  in  almost  similar  language.     He  says, 

I  cannot  dismiss  this  subject  without  calling  attention  to  the 


t( 


FRACTURES. 


299 


necessity  of  exercising  care  and  gentleness,  as  well  as  skill,  in  the 
examination  of  broken  limbs.     Nothing,  in  my  opinion,  betrays  a 
lack  of  judgment  as  well  as  of  common  humanity  on  the  part  of 
the  surgeon,  so  much  as  a  rude  and  reckless  handling  of  a  limb 
already  pricked  and  goaded  into  spasms  by  the  sharp  points  of  a 
broken  bone.     It  is  not  enough  to  say  that  such  rough  manipula- 
tion IS  generally  unnecessary;  it  is  positively  mischievous,  pro- 
voking the  muscles  to  more  violent  contractions,  increasing  the 
displacement  which  already  exists,  and  not  unfrequently  producing 
a  complete  separation  of  impacted,  denticulated,  transverse,  or 
partial  fractures,  which  can  never  afterwards  be  wholly  remedied 
augmenting  the  pain  and  inflammation,  and  not  unfrequently  I 
have  no  doubt,  determining  the  occurrence  of  suppuration,  gan- 
grene, and  death."  '  ^ 

The  patient  should  be  placed  in  the  most  comfortable  position, 
and  divested  of  all  unnecessary  clothing,  which  should  be  cut  off 
the  injured  hmb,  although  the  friends  may  seemingly  think  the 
garment  of  greater  value  than  the  limb.     Then,  sitting  down 
quietly  by  your  patient,  endeavor  to  inspire  confidence,  and  re- 
heve  his  mind  of  unnecessary  apprehension.     Place  your  finger 
upon  the  bone,  at  some  distance  from  the  site  of  injury,  and  then 
trace  along  its  course;  and,  when  the  bone  is  superficial,  the  diag- 
nosis will  be  easily  established.   If  there  be  much  pain  and  twitch- 
ing of  the  muscles,  they  may  be  palliated  by  the  application  of 
warm  water,  or  a  little  sweet  oil.     When  the  pain  is  intense,  or 
the  diagnosis  difficult,  making  a  protracted  and  strict  examination 
necessary,  chloroform  ought  to  be  administered.     It  would  seem 
hardly  necessary  to  say  that  the  diagnosis  should  be  made  irame- 
chately  after  the  injury ;   yet  the  young  practitioner  will  some- 
times feel  disposed  to  postpone  the  examination  until  he  has  con- 
suited  some  authority.     Now,  while  the  surgeon  ought  to  fortify 
himsolf  by  counsel,  he  should   not  defer  that  manipulation  by 
w  uch  he  IS  to  decide  *he  character  of  the  fracture.     The  swelling 
which  will  so  soon  follo-v,  will  render  the  examination  uncertain, 
perhaps  fruitless.     The  existence  of  unnatural  mobility,  and  the 
direction  of  the  fracture,  can  both  be  learned  by  lateral  pressure, 
an.l  gentle  rotation  of  the  limb.     And  in  this  way  crepitus  will 
also  often  be  elicited. 

In  those  cases  where  the  surgeon  cannot  satisfy  himsolf  as  to 


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300 


PRINCIPLES    OP    SURGERY. 


1 


the  exact  nature  of  the  fracture,  and  he  will  often  have  reason  to 
doubt,  he  should  express  himself  in  guarded  language.  And  when 
the  doubtful  point  is  one  involving  the  integrity  of  the  limb,  or 
the  life  of  the  patient,  he  should  suggest  the  propriety  of  a  con- 
sultation. 

Prognosis. — In  offering  an  opinion  as  to  the  length  of  time 
which  will  elapse  before  the  bone  will  be  restored,  many  things 
must  be  duly  considered.  First,  the  size  of  the  bone  must  be 
taken  into  account ;  the  larger  the  bone,  the  longer  will  be  the 
time  necessary  for  union  to  be  effected.  The  seat  of  fracture  will 
qualify  the  prognosis.  Speaking  generally,  the  opinion  will  be 
more  favorable  when  the  place  of  fracture  is  removed  from  the 
joint.  Again,  if  the  fracture  is  so  situated,  that  a  good  deal  of 
motion  may  be  expected  to  take  place,  union  will  not  so  expedi- 
tiously take  place.  The  number  of  muscles,  and  their  power  to 
contract,  by  which  the  fragments  may  be  displaced  will,  to  a 
greater  or  less  extent,  interfere  with  the  healing.  When  the  frac- 
ture is  oblique,  displacement  is  favored,  and  union  retarded.  The 
extent  of  injury  to  the  soft  parts  will  also  weigh  with  the  surgeon; 
for,  when  the  injury  has  been  severe,  there  will  be,  necessarily, 
some  intlammation,  which  always,  whatever  its  cause,  delays  the 
process  of  union,  and  should  pus  form,  there  will  be  a  serious 
complication,  so  that  the  resources  of  nature  will  be  more  seriously 
taxed.  Still,  again,  when  the  force  has  been  direct,  and  also  of 
great  violence,  by  which  the  bone  has  been  crushed,  or  commi- 
nuted, perhaps  denuded  of  periosteum,  or  in  some  other  way  de- 
prived of  its  ordinary  supply  of  blood,  as  when  the  wheel  of  a 
wagon,  heavily  laden,  passes  over  the  tibia,  the  restoration  will 
be  tardy,  perhaps  uncertain ;  the  leg  may  be  in  danger,  perhaps 
even  the  life,  or  some  local  disease,  as  caries,  may  follow.  Frac- 
ture near  a  joint,  accompanied  with  luxation,  will  prove  tedious 
and  uncertain  as  to  cure.  The  wound  of  a  large  artery,  or  an  in- 
jury to  a  large  nerve,  will  also  interfere  with  the  recovery. 
Finally,  the  age  and  health  of  the  patient  must  be  good,  in  order 
to  a  certain  and  perfect  union  of  bone. 


HEALING    PROCESS    OP    BONE. 


301 


CHAPTER    XXXVII. 

HealingProcessof  Bone:  Pathology-Treatment.  Three  Indications •  1 
Restore  Bone;  2.  Retain;  3.  Prevent  Inflammation.  Appliance  Band 
ages— Compresses— Splints.  ppnances.  nand- 

Bealing  Process  of  Bone.-In  speaking  of  the  "healing  pro- 
cess,  very  general  principles  have  been  given,  and  those  princi- 
ples apply  to  the  work  of  healing  in  bone  as  well  as  to  other 
tissues.  Those  principles  were  very  general,  because  they  are  so 
very  simple,  applymg  equally  to  all  tissues  of  the  body.  Sur- 
geons a  few  years  ago  would  have  hesitated  to  receive  the  state- 
ment  that  ^mmed^ate  union  of  bone  were  possible;  indeed,  it  is 
ut  yesterday  that  ,t  was  admitted  to  be  possible  in  the  softer 
IS  ues.  To  Mr.  Paget  are  we  particularly  indebted  for  the  eluci- 
dation  of  this  subject. 

In  immediate  union,  the  broken  ends  unite  "in  the  same  manner 
hat  the  soft  tissues  sometimes  unite,  by  the  direct  reunion  of  the 
broken  surfaces,  and  without  the  interposition  of  any  reparative 
ma  enal.  This  happens  not  unfrequently  in  the  spongy  bones, 
and  m  the  extremities  or  spongy  portions  of  the  long  bones,  espe! 
ml  y  when  one  portion  of  bone  is  driven  into  and  becomes  im- 
pacted,  as  m  certain  fractures  of  the  neck  of  the  humerus  or  of 
the  femur."    (Hamilton.) 

Mediate  union  is  the  most  frequent  form  ;  and  it  is  most  import- 
ant  to  understand  that  the  bond  of  union  may  be  very  limited  in 
thickness,  or  .t  may  be  very  great.    As  in  the  wound  of  soft  parts 
80  m  the  bone  :  a  scarcely  appreciable  portion  of  plasma  may  bathe 
the  broken  ends,  or  they  may  be  thickly  covered.    If  the  fracture 
|8  erniple,  and  the  fragments  be  retained  immovably  in  apposition, 
hen  there  will  be  no  irritation  to  lead  to  the  effusion  of  fibrin 
Instead  of  this  adventitious  matter,  there  will  be  direct  union  hv 
osseous  deposit.     The  greatness  of  this  principle  will  become  ap- 
parent  when  we  come  to  consider  the  treatment  of  fracture.    The 
01.1  (ioctrine  of  provisional  and  subsequent  definitive  callus  beinit 
necessary  steps  in  the  process  of  cure,  is  now  tottering  to  its  fall  • 


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302 


PRINCIPLES    OF    SURGERY. 


neither  provisional  nor  definitive  callus  is  necessary.  The  former 
is  never  seen  in  the  cure  of  a  simple  fracture,  if  the  surgeon  can 
but  succeed  in  keeping  the  bones  together  and  strictly  at  rest. 
Callus  is  only  thrown  out  within  and  around  the  ends  of  the  frag- 
ments, when  the  surgeon  fails  to  supply  a  retentive  apparatus. 
The  definitive  callus  will  be  very  little  if  the  pieces  are  properly 

and  securely  adjusted.  When  the  sharp 
broken  ends  are  allowed  to  move,  they  will 
cause  pain,  irritation,  congestion,  and  the 
elaboration  of  fibrin,  which  nature  intends, 
n  her  wise  way,  to  convert  into  a  hard 
substance  to  hold  the  ends  together,  and  a 
very  little  of  this  may  prove  sufficient. 
There  may,  indeed,  be  only  what  was  for- 
merly designated  definitive  callus — simply 
a  bond  of  union  between  the  broken  ends. 
When  the  quantity  is  greater  it  will  then 
also  occupy  the  medullary  canal,  constitu- 
ting the  "interior  callus,"  or  the  plug.  In 
connection  with  this,  there  will  likely  be  a 
quantity  around  the  ends  of  the  bones,  thus 
"  ensheathing"  it.  This  latter  may  exist 
without  the  definitive  being  detected;  in 
such  cases,  probably,  the  bond  of  union  was 
limited,  and  afterwards  speedily  absorbed. 
It  will  therefore  be  understood,  that  con- 
tinued moving  of  the  bone  when  it  ought 
to  be  in  a  state  of  repose,  will  lead  to  the 
deposit  of  a  large,  perhaps  unlimited  quan- 
tity of  fibrin :  and  it  will  be  found,  that  in 
those  cases  where  there  is  exuberant  callus, 
there  had  been  continued  irritation,  from 
unceasing  motion  of  the  bone.  And  when  there  is  lapping  of 
bone  there  will  be  still  more  irritation,  yet  no  more  than  is  requi- 
site to  call  forth  that  amount  of  reparative  material  which  is 
required  to  fix  the  fractured  ends. 

The  whole  pathology,  then,  is  summed  up  in  this :  that  in  the 
union  of  broken  bones,  no  more  provisional  matter  is  formed  than 
is  necessary  to  constitute  a  bond  of  union ;  that  in  a  simple  frac- 


HEALING    PROCESS    OF    BONE. 


303 


ture  but  little  or  no  provisional  material  is  supplied,  if  the  frag- 
ments be  retained  in  a  state  of  repose,  as  in  that  case  nature  will 
proceed  directly  to  unite  the  divided  osseous  fibres  by  osseous  de- 
posit;  and  that  when  there  is  provisional  matter,  it  results  from 
occasional  or  continued  motion  of  the  fragments.  The  conclusion 
to  be  drawn  from  the  foregoing  facts  is,  that  if  the  surgeon  fails 
to  supply  splints,  nature  endeavors  to  supply  them ;  and  the  pro- 
visional callus  thus  called  into  existence  has  been  appropriately 
termed  nature's  splints. 

In  those  cases  of  fracture  where  there  is  some  local  complica- 
tion, mliammation  is  likely  to  take  place,  and  consequently  healing 
IS  impossible  until  the  inflammation  subsides.  Following,  there 
will  be  no  regular  course  of  healing;  yet  there  will  be  a  wise 
arrangement  of  nature  by  which  a  process  of  repair  will  take 
place,  strikingly  analogous  to  healing  by  granulation  in  the  soft 
parts.  If  the  patient  be  healthy,  and  the  part  placed  in  a  proper 
position,  healing  will  with  rapidity  follow,  unattended  with  much 
discharge. 

It  is  convenient  to  divide  the  organization  of  provisional  callus 
into  stages:  first,  the  effusion  of  the  lymph;  second,  its  coagula- 
tion ;  third,  its  period  of  life ;  fourth,  substitution  of  bony  matter 
for  the  provisional  material,  and  removal  of  all  the  adventitious 
substance  by  absorption. 

The  steps  by  which  organization  is  accomplished  are  the  same 
as  those  we  have  traced  before.  ( Vide  Healing  Process.)    Through 
the  agency  of  new  vessels,  the  organized  fibrin  is  gradually  super- 
seded by  osseous  tissue.     During  the  first  stage,  while  the  lymph 
18  being  effused,  there  will  be,  even  in  a  simple  fracture,  some 
swelling;  and  during  the  second  stage,  circumscribed  swelling  will 
generally  exist.     Thereafter,  the  appearance  of  the  limb  will  in 
many  cases  be  natural,  except  when  the  provisional  callus  is  ex- 
tensive.    At   first  this   is   flexible;   but  as  the  osseous  matter 
increases,  the  substance  becomes  more  firm,  and  finally  unyielding. 
During  this  process  of  changing,  it  will  at  first  become  cartilagi* 
nous  m  consistence,  and  finally  osseous.     As  long  as  this  is  yield- 
mg,  the  limb  should  be  retained  at  rest ;  and  should  the  pieces 
have  become  united  at  an  angle,  the  bone  may,  by  proper  pressure, 
be  brought  into  its  natural  shape. 
The  time  required  for  the  work  to  Ha  Pnmnlofo,!  »;ii  a i 


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304 


PRINCIPLES    OF    SURaBEY. 


Wt: 


upon  the  size  of  the  bone,  the  absence  of  inflammatory  action, 
and  the  state  of  quietude  in  the  broken  bones ;  also  the  health, 
age,  and  general  condition  of  the  patient  and  of  the  tissues  in  the 
part. 

In  a  healthy  subject,  after  a  fracture  has  united,  the  bone  is 
quite  as  strong  as  ever ;  and  often,  when  the  limb  is  subsequently 
exposed  to  violence,  fracture  will  more  quickly  take  place  else- 
where. 

Treatment  of  Fracture. — Associated  with  the  various  remedial 
measures,  is  the  course  of  procedure  which  ought  to  be  observed 
by  the  surgeon  in  superintending  the  removal  of  the  patient  when 
he  is  unable  to  walk.  Fractures  more  generally  occur  to  persons 
when  away  from  home ;  and  before  the  first  step  can  be  taken  in 
the  treatment,  the  patient  requires  to  be  removed  to  the  bed  upon 
which  he  is  to  lie.  The  surgeon,  if  called  immediately,  will  have 
the  patient  placed  upon  a  stretcher — an  old  door  is  very  good, 
made  comfortable  by  the  coats  of  those  present  who  may  be  will- 
ing to  administer  to  his  comfort.  The  surgeon  will  himself  have 
the  immediate  care  of  the  broken  limb,  not  only  to  secure  the 
greatest  ease  to  the  patient,  but  as  well  to  prevent  displacement, 
from  which  the  case  would  be  complicated.  Having  reached  the 
house,  he  should  see  that  the  chamber  and  bed  are  fully  prepared 
for  the  patient's  reception,  and,  in  carrying  him  into  the  bedroom, 
have  it  done  in  such  a  way  as  will  allow  transferring  of  the  pa- 
tient to  the  bed  with  the  least  pain  and  disturbance  of  the  limb. 

The  patient  duly  settled  in  bed,  place  the  broken  limb  in  a  com- 
fortable position — and  very  much  is  embraced  in  the  word  comfort- 
able, for  if  a  broken  limb  can  be  so  placed,  the  work  of  repair 
will  forthwith  commence.  That  is  to  say,  it  does  not  necessarily 
follow  that  because  a  certain  kind  of  fracture  exists,  a  particular 
kind  of  apparatus  must  be  in  use  before  repair  can  commence. 
The  only  thing  requisite  is  to  make  the  limb  comfortable,  and,  of 
course,  to  keep  it  so.  And  as  a  general  thing,  when  the  limb  is 
free  from  pain,  the  position  of  the  broken  bone  will  not  be  far  from 
the  natural  one. 

The  three  principal  indications  in  the  treatment  of  fracture  are, 
Ist,  to  restore  the  fragments  to  their  natural  position,  by  the  doing 
of  which  the  limb  will  be  brought  into  its  natural  shape ;  2d,  to 


HEALING    PROCESS    OP    BONE.  305 

"Setting"  the  bone  is  an  operation  which  the  patient  very 
much  dreads,  and  for  which  the  surgeon  is  allowed,  more  particu^ 
larly,  to  charge  his  fee.  But  if  the  surgeon  will  go  care?ully  to 
work  inde  diagnosis),  in  the  majority  of  cases  the  pain  wil/not 
be  so  very  great ;  and  the  surgeon  well  kno^s  that  the  bones  may 
be  p  aced  a  dozen  times  in  proper  relationship,  and  be  as  often 
displaced  by  muscular  action,  or  by  the  weight  of  the  limb.  The 
real  difficulty  zs  not  tn  Betting  the  bone,  but  in  keeping  it  set. 

To  carry  out  the  first  indication,  no  definite  rules  can  be  given 
Thestepsto  be  taken  will  depend  upon  the  bone  fractuel  and 
the  nature  of  the  fracture.     Over  and  above  what  may  be  done 
mthe  examination,  to  establish  the  diagnosis,  nothing  need  be 
attempted  until  the  apparatus  which  the'case' demand's  illul^ 
prepared.     Indeed  the  surgeon  should  avoid  disturbing  the  patient 
1 11  he  IS  quite  ready  to  apply  the  splints.     The  nature  of  the  dis- 
placement,  if  any  exist,  will  be  duly  considered ;  and  as  the  first 
and  prmcipal  thing  is  to  replace  the  bone,  the  cause  of  the  dis- 
placement must,  If  possible,  be  removed.     Muscular  action  is  the 
most  frequent  cause  of  displacement,  and  to  overcome  it,  the  sur! 
geon  has  been  recommended  to  employ  extension  and  counter- 
xtensu,n.     This  is  a  practice  which  cannot  be  too  earnestly  con- 
damned.     Now  and  then  force  may  be  necessary,  but  they  are 
exceptional  cases.     When  the  displacement  has  retlted  from  e" 
ternal  force,  or  from  the  falling  of  the  limb  or  body,  a  broken  end 
may  have  been  driven  into  the  soft  tissues,  and  the'i^e  remain      In 
such  cases  extension  will  be  necessary  to  extract  it.     When  the 
nds  lap  from  muscu  ar  contraction,  the  parts  may  undoubtedly 

he  b  r       n"^  'f '"  ''  *'^  ""''  ^"^'  -^-«  i^  b«  -ntinued"^ 
e  bones  w.11  relapse  into  their  former  state.     It  will  thus  be  seen 

t  at  only  when  the  end  of  a  piece  is  driven  into  the  soft  tissues 

should  extension  be  resorted  to.     Not  only  is  this  practice  unnel 

essary,  but  it  is  very  objectionable.     Manipulation  of  any  kind 

tZ  .  '^^^^"^T^^^^on.     The  best  proof  of  this  is,  that 

.t  causes  pain  to  the  patient;  audit  cannot  be  wondered  at.  The 
parts  around  the  fracture  are  irritated,  often  lacerated.  The 
periosteum  at  the  part  is  intensely  congested,  and  in  a  simple  frac- 

20 


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LluiiJuh 


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'      tl 


306 


PRINCIPLES    OF    SURGERY. 


ture  it  may  be  only  partially  severed.  Now,  drawing  upon  the 
bone  will  increase  the  irritation,  and  intensify  the  congestion  ;  and 
when  the  periosteum  be  not  altogether  separated,  it  will  quite  ac- 
complish it ;  and  still  more,  the  muscles  will  sympathize  with  the 
part  irritated,  and  resist  the  efforts  made  to  overcome  their  action, 
for  they  are,  to  a  great  extent,  guardians  of  the  bone,  and  con- 
tract involuntarily  when  the  bone  is  in  pain,  and  then  will  cease 
to  contract  when  the  parts  are  placed  in  an  easy  position.  We 
now  come  to  the  essential  point:  how  are  we  to  overcome  that 
muscular  action  which  produces  and  keeps  up  displacement  of  bone? 
Now,  instead  of  attempting  to  do  this  by  extension  and  counter- 
extension,  efforts  should  be  made  to  so  flex  the  limb  or  body  as 
that  the  engaged  muscles  may  be  relaxed.  When  all  of  the 
muscles  are  in  a  state  of  quietude,  the  broken  pieces  will  naturally 
take  their  ordinary  position  in  relation  to  each  other.  And,  if  no 
cause  of  displacement  be  in  operation,  the  first  indication  in  the 
treatment  of  fracture  is  thus  fully  met.  With  one  notable  excep- 
tion, that  is  fracture  of  the  femur,  almost  every  fracture  to  which 
the  bones  of  the  body  are  liable,  may  be  treated  on  this  principle. 
Keeping  this  in  view,  much  can  be  done  by  soothing  the  system 
generally,  by  quieting  apprehension,  and  by  the  local  application 
of  anodynes. 

When  extension  is  necessary,  it  should  be  made  with  gentleness, 
yet  with  suflScient  firmness ;  but  avoid  sudden  or  violent  force. 
While  extension  is  being  made  by  an  assistant,  the  surgeon  will, 
by  direct  manipulation,  endeavor  to  mould  the  limb  into  its  pro- 
per form.  Sometimes  a  fragment  is  drawn  out  of  place  by  the 
action  of  a  single  muscle,  or  the  weight  of  the  limb ;  it  is  in  such 
cases  more  than  useless  to  attempt  to  force  it  into  place  by  pres- 
sure ;  the  only  way  is  to  support  the  pieces  in  that  position  which 
will  allow  them  to  come  together. 

The  second  indication  is  to  retain  the  fragments  in  their  natural 
position,  and  so  surely  that  all  kinds  of  motion  will  be  prevented. 
To  do  this,  mechanical  means  are  generally  necessary.  In  per- 
sons of  mature  age,  who  will  voluntarily  keep  a  limb  in  a  required 
position,  by  night  and  by  day,  but  slight  means  will  be  necessary 
to  meet  the  requirements ;  yet  such  procedure  is  not  unattended 
with  risk. 

Rest  of  the  body,  proper  position  of  the  body  and  of  the  injured 


HEALING    PROCESS    OF    BONE. 


307 


limb,  baiidages,  compresses,  and  splints  or  other  apparatus,  are  the 
means  bj  which  the  bones  may  be  kept  together.  In  order  to 
secure  rest  to  the  body,  the  bed  should  be  so  made  as  to  meet  the 
wants  of  the  patient,  and  as  to  suit  the  position  in  which  the  leg 
will  require  to  be  placed.  As  to  position,  a  natural  one  is,  gene- 
rally  speaking,  the  most  comfortable  one,  and  it  will  favor  relaxa- 
tion ot  the  muscles,  which  is  so  desirable. 

With  respect  to  appliances,  I  will  give  what  I  conceive  to  be  a 
valuable  rule,  and  which  I  have  often  urged  in  the  class-room, 
namely,  to  use  as  few  splints  and  bandages  as  will  secure  the  required 
object     If  a  bandage  will  do  the  work,  then  apply  no  splint;  if 
one  sphnt  wM  answer,  do  not  use  two.     The  various  appliances 
should  be  of  the  lightest  material  which  will  meet  the  wants  of  the 
case.     Keeping  the  above  principle  in  view,  it  will  be  understood 
that  no  bandage  should  be  applied  directly  to  the  limb,  before  the 
splmt  or  splints  are  adjusted.     The  bandage  is  used  principally  to 
fasten  the  splint,  bu^  it  will  also,  by  its  uniform  pressure,  prevent 
to  some  extent  spasmodic  action  of  the  muscles,  and  give  general 
support  to  the  limb.     But  the  latter  advantage  is  quite  as  well 
secured  by  the  application  of  the  bandage  over  the  splints.     To 
protect  the  skm  from  irritation  by  the  splint,  padding  of  cotton  or 
wool  can  be  used. 

When  the  splints  are  prepared,  the  limb  will  be  bandaged  from 

he  extremity  upward,  until  the  point  is  reached  to  which  the 

lower  end  of  the  splint  will  reach.    Then  the  splint  or  splints  having 

been  placed  m  their  proper  position,  the  bandage  will  be  continued 

over  them,  and  up  the  limb  so  as  to  securely  fix  the  whole 

A  bandage  applied  under  the  splints  is  not  only  useless,  but  it 
IS  hkely  to  prove  injurious.  The  surgeon  has  to  inspect  the  seat 
of  fracture  almost  daily,  and  the  existence  of  two  bandages  will 
materially  obstruct  the  necessary  view ;  to  remove  one  would  be  to 
expose  the  bone  to  redisplacement.  A  more  urgent  objection  is 
the  fact  that  m  all  fractures  there  will  be  some  swelling  after  the 
application  of  the  bandage,  especially  if  the  bandage  is  at  all 
t'ghtly  applied,  and  pain  will  result,  which  may  lead  to  inflamma- 
tion. To  counteract  this  evil,  it  should  be  in  the  power  of  the 
surgeon  to  loosen  the  bandage  at  any  time :  this  can  only  be  done 
when  It  IS  not  immediately  applied  to  the  skin ;  at  least,  without 
disturbing  the  splints.     I  have  generally  secured  the  necessary 


'  '  J  •   !1 


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I 


308 


PRINCIPLES    OF    SURaERY. 


relief  in  this  respect,  '  y  partially  dividing  the  bandage,  here  and 
there,  and  afterwards,  when  tho  swelling  had  subsided,  united 
them  again  with  a  needle  and  thread.  Moreover,  when  a  soft  pad 
is  placed  under  the  splints,  there  will  be,  to  some  extent,  an  ac- 
commodation of  the  splint  to  the  swelling  limb. 

There  are  two  kinds  of  bandages,  the  roller  and  the  many-tailed 
bandage,  or  the  bandage  of  Scultetus.  The  roller  or  continuous 
bandage  is  preferable  for  general  use,  as  it  can  be  more  evenly 
applied,  and  its  position  is  less  likely  to  change.  It  is  commonly 
used  in  simple  fractures.  When  the  fracture  is  compound,  or 
there  is  a  wound,  or  any  other  serious  local  complication,  the  other 
form  of  bandage  will  be  found  more  advantageous,  because  of  the 
facility  it  affords  to  examine  at  any  time  the  injured  part.  The 
increased  advantage  of  the  Scultetus  bandage  is,  that  when  there 
is  a  discharge  from  the  wound,  one  or  more  pieces  can  be  removed, 
and  clean  ones  substituted.  This  may  be  done  even  without 
moving  the  broken  limb,  by  pinning  fast  the  clean  strip  to  the  one 
about  to  be  removed,  so  that  when  the  latter  is  withdrawn,  the 
former  will  follow  it  into  position  under  the  limb. 

In  the  fracture  of  smaller  bones,  I  have  used  adhesive  strips  to 
hold  the  splints,  and  have  found  them  to  be  an  excellent  substitute 
for  the  bandage.  A  few  are  sufficient,  and  they  leave  the  limb  to 
a  great  extent  uncovered. 

Compresses  are  sometimes  called  into  use;  perhaps  too  fre- 
quently. There  cannot  be  a  more  mischievous  procedure  than  to 
fix  a  compress  upon  the  broken  end  of  a  bone  which  is  displaced 
by  muscular  action,  as  in  fracture  of  the  femur  when  the  psoas 
and  iliacus  act  upon  the  lower  end  of  the  upper  fragment.  As 
elsewhere  explained,  the  lower  fragment  ought,  if  practicable,  to 
be  brought  upward,  so  as  to  be  in  relationship  with  the  upper  one. 
Again,  a  compress  should  never  be  employed  to  force  into  place 
an  unreduced  bone,  as  it  may  lead  to  serious  complication.  The 
only  use  to  which  it  can  be  properly  put  la  U  -novoat  any  slight 
disturbance  to  which  the  limb  may  be  '  Kf>->i»  a.  The  prec.u-j 
should  never  be  so  great  as  to  interfere  witn  liie  capillary  circula- 
tion; otherwise,  sloughing  or  gangrene  may  follow,  lamentable 
cases  of  which  have  come  under  my  notice.  The  compress  may 
be  of  cotton  folded,  f  •  of  wool. 

.Splints. — Let  it  b     emembered,  the  splint  should  always  be  as 


HEALING    PROCESS    OP    BONE. 


309 


light  in  weight  and  limited  in  thickness  as  is  consistent  with  the 
object  to  be  secured. 

It  may  be  made  of  a  variety  of  materials,  such  as  metals  of 
various  kinds,  reeds,  unbroken  straw  in  bundles,  wood,  leather, 
pasteboard,  or  millboard,  gutta-percha,  cloth  stiffened  with  gum, 
cotton  with  starch,  plaster  of  Paris,  &c.     As  a  general  thing,  the 
splint  should  be  especially  prepared  for  the  case.     So  varied  are 
the  fractures  in  the  same  bone,  and  in  the  same  locality,  and,  at 
the  same  time,  so  unlike  are  the  limbs  of  any  two  persons,  that 
the  surgeon  will  find  it  impossible  to  adapt  a  set  of  splints  to  every 
patient.     I  have  had  the  honor  of  enunciating  these  views  in  the 
class-room  each  year  of  my  teaching;  but  so  admirably  are  they 
advocated  by  Hamilton,  that  I  cannot  do  better  than  give  his 
words  on  the  subject.     He  says :  "  But  I  wish  at  once,  and  for  all, 
to  disclaim  any  intention  of  giving  even  a  qualified  approval  of 
any  of  those  carved,  polished,  and  generally  patented  wooden 
splints,  which  are  manufactured  and  sold  by  clever  mechanics,  and 
which  one  may  see  suspended  in  almost  every  doctor's  oflice, 
whether  in  the  city  or  in  the  country.     Constructed  with  grooves 
and  ridges,  and  variously  inclined  planes,  for  the  avowed  purpose 
of  meeting  a  multitude  of  indications,  such  as  to  protect  a  condyle, 
to  press  between  parallel  bones,  to  follow  the  subsidence  of  a 
muscular  swelling,  &c.,  they  never  meet  exactly  a  single  one  of 
these  indications,  whilst  they  seldom  fail  to  defeat  some  other  in- 
dication of  equal  importance.     They  deceive  especially  the  inex- 
perienced surgeon  into  the  belief  that  he  has  in  the  splint  itself,  a 
provision  for  all  these  wants,  and  consequently  lead  him  to  neglect 
those  useful  precautions  which  he  would  otherwise  have  adopted." 
I  taught  these  views  years  before  I  saw  this  excellent  work ;  but 
so  important  are  they,  that  I  desire  to  give  them  the  weight  of 
this  high  authority. 

A  shingle  or  a  bit  of  cedar,  or  a  cigar-box,  can  at  any  time  be 
quickly  made  into  a  splint  so  shaped  as  to  fit  the  limb,  and  covered 
perhaps  with  cotton-wool  and  a  bandage.  I  have  often  made  an 
excellent  splint  of  sole-leather,  or  thick  upper  leather.  A  very 
useful  splint  is  sometimes  made  by  veneering  a  calfskin  or  a  sheep- 
skin with  thin  strips  of  light  wood.  "Felt,  made  of  wool,  satu- 
rated  with  gum  shell-lac,  and  pressed  into  sheets,  makes  an  excel- 
lent moulding  tablet  for  splints."     "A  much  cheaper  material  is 


!    .M 


'ili 


310 


PRINCIPLES    OF    SURGERY. 


an  old  piece  of  broadcloth,  or  any  similar  closely  woven  texture 
by  saturating  it  thoroughly  with  gum  shell-lac,  the  gum  being  dis- 
solved in  alcohol  in  the  proportions  of  one  pound  of  the  former  to 
two  quarts  of  the  latter.  Thus  prepared,  it  is  to  be  spread  upon 
both  surfaces  of  the  cloth  with  a  common  paint-brush ;  a  second 
and  third  coat  must  be  spread  upon  one  of  these  surfaces  after 
they  are  dry."     (Hamilton.) 

Gutta-percha  is  very  good  for  splints,  but  less  expensive  mate- 
rial will  answer  equally  well. 

"  In  1834,  Luctin,  of  Brussels,  introduced  the  use  of  starch  as 
a  means  of  hardening  the  bandages,  his  method  of  using  which  is 
essentially  as  follows:  A  dry  roller  is  first  applied  to  the  skin, 
and  then  smeared  with  starch,  all  of  the  bony  prominences  and 
irregularities  of  the  limb  are  filled  up  or  covered  with  cotton  bat- 
ting, charpie,  down,  &c. ;  strips  of  pasteboard,  or  of  binders' 
board,  moistened  and  covered  also  with  starch,  are  now  laid  along- 
side the  limb,  over  which  again  are  turned  in  succession  one,  two, 
or  three  layers  of  the  starched  roller ;  the  number  of  rollers  and 
the  thickness  of  the  pasteboard  being  proportioned  to  the  size  of 
the  limb,  or  to  the  required  strength  of  the  splint.  The  whole  is 
completed  by  starching  the  outside  of  the  last  bandage. 

"This  dressing  will  generally  become  dry  within  from  thirty  to 
forty  hours,  which  process  may  be  expedited  by  exposing  its  sides 
as  much  as  possible  to  the  air,  or  by  the  application  of  artificial 
heat  with  bags  of  dry  sand,  or  with  hot  bricks. 

"  As  soon  as  the  bandages  are  dry,  they  are  to  be  cut  along  the 
front  to  a  sufficient  extent  to  permit  of  an  examination  of  the 
limb,  and  then  closed  with  an  additional  roller. 

"  On  the  third  or  fourth  day,  or  as  soon  as  the  subsidence  of 
the  swelling  may  render  it  necessary,  the  bandages  should  be  cut 
open  through  their  whole  extent,  the  edges  pared  off  and  brought 
together  again  snugly  witli  an  additional  roller. 

"For  myself,  I  am  quite  as  much  in  the  habit  of  using  wheat 
flour  paste  as  either  starch  or  dextrine,  and  if  properly  made  it 
dries  about  as  quickly  as  the  starch,  and  is  equally  firm."  (Hamil- 
ton.) 

In  accordance  with  the  principle  that  no  unnecessary  ap{)lica- 
tion  should  be  employed,  this  form  of  bandage,  called  the  immov- 
able apparatus,  ought  not  to  be  used  except  when  there  is,  from 


HEALING  PROCESS  OF  BONE. 


811 


some  cause,  delayed  union  of  bone.  In  no  case  should  the  bandage 
be  prepared  before  such  swelling  as  may  be  expected,  has  reached 
Its  maximum.  The  practice  recommended  by  some,  of  applying 
the  starch  bandage  immediately  after  the  injury  is  most  question- 
able. 

The  third  indication  in  the  treatment  of  fracture,  is  to  prevent 
inflammation;  and  if  it  exist,  to  endeavor  to  control  it,  and  pre- 
vent suppuration. 

In  a  simple  fracture  no  inflammation  should  follow,  nor  will 
there,  if  the  first  two  indications  be  properly  carried  out.     When, 
however,  there  is  a  complication,  such  as  bruising,  or  laceration  of 
the  tissues  within,  a  degree  of  inflammation  may  be  expected  to 
follow.     The  surgeon  cannot  be  held  responsible  for  existing  com- 
plications at  first,  but  he  may  be  for  those  which  subsequently 
arise.     Sometimes,  even  in  a  simple  fracture,  there  will  be  a  great 
deal  of  pain,  due  probably  to  un  injured  nerve,  or  perhaps  to  a 
spicula  of  bone,  or  it  may  be  extreme  nervousness.     This  may  be 
to  some  extent,  relieved  by  the  application  of  anodynes,  or  by 
their  internal  exhibition.     In  a  simple  fracture,  however,  when 
there  is  no  pain,  no  applications  whatever  should  be  employed. 
Washing  the  part  will  prove  beneficial,  but  nothing  else. 

At  any  time  after  splints  and  bandages  have  been  adjusted,  it 
matters  not  with  how  much  care,  should  pain  and  swelling  com- 
mence, indicating  danger  of  inflammation,  the  bandages  must  be 
loosened,  and  if  that  do  not  suffice,  thev  and  the  splints  must  be 
removed  until  ease  is  obtained.  Healing  cannot  commence  so  long 
as  there  is  pain  and  inflammation,  and  therefore  when  they  arise, 
the  surgeon's  attention  will  be  exclusively  directed  to  their  sup* 
prcssion,  treatment  being  based  on  general  principles.  Should  an 
abscess  form,  it  will  have  to  be  duly  opened. 

The  surgeon  ought  to  inspect  the  limb  daily  for  several  days, 
to  see  that  it  is  perfectly  comfortable.  Attention  to  a  very  little 
thing  in  time  may  prevent  serious  mischief.  Phlyctsena  may  form, 
when  they  ought  to  be  emptied,  at  the  same  time  preserving  the 
cuti'^le.  During  convalescence  the  surgeon  must  give  due  caution 
against  .secondary  fracture,  else,  if  it  occur,  he  may  be  blamed. 
When  the  fracture  is  situated  near  a  joint  care  must  be  token  lest 
there  be  partial  anchylosis  for  a  while. 


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PRINCIPLES    OF    SURGERY. 


CHAPTER    XXXVIII. 

Treatment  of  Compound  Fracture :  Irregular  Callus— Causes— Treatment- 
Exuberant  Callus— False  Joint— Causes— Treatment— Diastasis. 

Treatment  of  Compound  Fracture. — If  the  peculiar  wound  par- 
take of  the  cl  tracter  of  the  incised,  it  may  soon  heal,  and  thereby 
the  compound  be  converted  into  a  simple  fracture.  When,  how- 
ever, the  soft  parts  are  so  injured  that  healing  will  have  to  take 
place  by  granulation,  then  healing  of  bone  and  of  the  soft  tissues 
must  progress  together.  At  first  attention  will  be  directed  to 
those  measures  which  will  prevent  or  lessen  inflammation.  ( Vide 
Treatment  of  Wounds.)  The  principal  indication  at  first,  so  far 
as  the  fracture  is  concerned,  is  to  place  the  limb  in  a  comfortable 
position,  supported  by  an  apparatus  so  arranged  that  due  atten- 
tion can  be  given  to  the  wound,  to  cleanliness,  &c.  When  heal- 
ing is  about  to  begin,  then  the  ends  of  the  bone  should  be  so 
moulded  that  the  proper  form  and  length  of  the  limb  will  be  se- 
cured. Gradual  and  continued  extension  of  the  limb  will  often 
accomplish  this.  Or  the  application  of  a  starch  bandage,  with  an 
opening  in  it  at  the  seat  of  the  wound,  will  often  answer  those 
ends ;  and  perhaps  allow  the  patient  to  move  about.  This,  how- 
ever, is  more  likely  to  be  practicable  when  the  union  of  the  bone 
is  far  advanced. 

In  a  recent  compound  fracture  the  question  may  present  itself: 
can  the  limb  be  saved?  No  fixed  rule  can  be  given ;  but,  in  ac- 
cordance with  the  principles  of  modern  conservative  surgery,  if 
there  be  but  a  slight  chance  for  recovery  the  patient  should  have 
the  benefit  of  that  chance.  The  powers  of  nature  are  often  very 
great.  If  the  main  vessels  and  nerves  be  uninjured,  the  surgeon 
ought  not  to  despair,  unless  there  be  some  other  cause  of  dopres- 
eion.  And,  if  the  age,  habits,  and  other  circumstances  be  favora- 
ble, no  matter  how  much  bruising,  or  tearing,  or  comminution  of 
bone,  an  cff"ort  should  be  made  to  Have.  Of  course  the  dangers  are 
not  a  few.  The  shock  is  often  groat.  There  may  have  been  loss 
of  blood,  and  the  discharge  may  be  exhausting.  Tetanus  may 
supervene,  and  therefore  the  surgeon  will  not,  without  profound 


TREATMENT  OP  COMPOUND  FRACTURE. 


313 


deliberation,  or  a  consultation,  decide  as  to  which  is  the  most  judi- 
cious course. 

But  when  the  limb  is  literally  crushed,  as  by  a  railway  carriage; 
or  a  joint  is  seriously  involved ;  or  the  vessels  or  nerves  destroyed, 
amputation  will  be  the  only  procedure  which  can  be  adopted. 

The  time  at  which  the  operation  should  be  performed  will  de- 
pend upon  the  state  of  the  patient.  Convinced  that  the  limb  must 
be  removed,  the  earlier  it  is  done  the  better  for  the  patient,  but  if 
the  shock  has  been  great,  it  will  be  necessary  to  wait  until  he  has 
rallied.  At  any  time  during  the  course  of  treatment,  if  the  in- 
jured limb  seems  to  be  a  source  of  irritation  and  exhaustion  be- 
yond what  the  system  can  endure,  ampu- 
tation must  at  once  be  resorted  to. 

Irregular  Callus  or  Deformity. — From 
what  has  been  said  with  regard  to  the 
healing  process  of  bone,  it  will  be  un- 
derstood that  the  quantity  of  "en- 
sheathing"  "provisional  callus"  will  de- 
pend upon  the  degree  of  pain,  and  the 
amount  of  motion  at  the  seat  of  fracture. 
When  there  is  continued  displacement, 
and  unnatural  contraction  of  muscles,  the 
reparative  material  is  extensively  thrown 
out,  and  thus  efforts  are  seemingly  made 
to  grasp  the  moving  bones  and  hold  them, 
80  as  to  prevent  motion.  But  this  is  not 
effected  until  the  fragments  are  displaced 

by  the  constant  motion.    In  this  way  the 

callus  often  becomes  irregular,  while  at 

the  same  time  and  from  the  same  cause, 

there  is  perceptible  deformity. 

Games. — Certain  kinds  of  fracture  are 

disposed  to  this  unfortunate  evil,  that  is 

those  which  are  with  great  difficulty  re- 
tained perfectly  still.    Neglect  or  unskil- 

fill  treatment  is  too  often  the  cause.    Not 

unfrequcntly  wilfulness  of  the  patient  is 

the  sole  cause  ;  that  is,  by  persistently 

disobeying  the  surgeon's  directions. 


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314 


PRINCIPLES    OF    SURGERY. 


Treatment. — The  callus  remains  pliable  for  a  time,  sometimes 
a  protracted  period ;  and  while  it  is  yielding,  the  deformity  may 
be  remedied  by  extension  of  the  limb,  and  by  judicious  pressure. 
Dupuytren  records  several  cases  where  a  cure  was  thus  effected. 
A  aeton  passed  through  the  part  to  produce  suppuration,  may  so 
soften  the  new  material  as  to  allow  replacement  by  extension. 
Another  method,  sometimes  practised,  is  to  forcibly  break  the 
crooked  bone — to  rupture  the  callus.     But  this  procedure  must 
not  be  rashly  adopted.     If  the  callus  is  abundant  and  has  become 
very  firm,  which  may  be  the  case,  the  force  requisite  to  break  it 
will  be  very  great,  and  more  especially,  as  there  will  be  danger  of 
breaking  the  bone  elsewhere.     The  following  points  must  be  fully 
estimated :  the  length  of  time  since  the  fracture,  the  size  of  the 
bone,  the  situation  in  the  bone,  the  age  of  the  patient,  &c.,  and 
also,  the  degree  of  deformity,  to  what  extent  the  function  of  the 
limb  is  impaired,  his  situation  in  life,  and  his  own  desires.    Having 
determined  to  rupture  the  callus,  let  chloroform  be  given  to  the 
patient ;  then  seize  the  bone,  and  so  apply  force,  as  to  concentrate 
it  at  the  desired  point.     I  have  seen  an  apparatus  used  by  Dr. 
Buck,  of  New  York,  the  nature  of  which  I  now  forget.     After  the 
bone  is  rebroken,  the  same  treatment  will  be  pursued  as  in  an 
original  fracture.     It  is  recommended,  when  the  callus  is  so  firm 
that  it  may  not  be  ruptured,  to  resect  it  by  the  aid  of  the  saw. 
This  operation  may  be  followed  by  some  shortening ;  but  even  that 
may  be  preferable  to  the  deformity. 

Exuberant  Callus  is  sometimes  met  with  when  the  limb  is  even 
quite  straight.  In  such  cases  there  must  be  some  cause  of  Irrita- 
tion, leading  to  the  unnecessary  elaboration  of  reparative  material. 
It  may  be  an  irritated  nerve,  or  a  spicula  of  bone,  which,  being 
frequently  moved,  keeps  up  the  pain.  Whatever  the  cause,  it 
must,  if  possible,  be  removed.  Tlie  superfluous  callus  may  be  ab- 
sorbed, or  itself  become  a  source  of  continued  irritation,  rendering 
its  removal  absolutely  necessary. 

False  Joint — Pseudarthrosis. — Nothing  more  unfortunate  can 
befall  the  surgeon,  especially  a  young  one,  than  to  have  a  case  of 
fracture  which,  after  the  usual  course  of  treatment,  remains  unu- 
nited. The  limb  has  been  kept  in  the  proper  apparatus,  suffi- 
ciently at  rest,  and  the  length  of  time  usually  prescribed.  Nothing 
untoward  has  attended  the  treatment,  and  the  surgeon  has,  with 


TREATMENT    OP    COMPOUND    FRACTURE.  315 

some  confidence,  declared  that  the  limb,  upon  removing  the  splints, 
will  be  found  altogether  well-the  union  perfect.     But  to  his  great 
chagrin,  it  is  found  to  be  as  when  it  was  placed  in  the  splints- 
that  there  is  non-union.     Such  will  now  and  then  be  the  experi- 
ence of  the  most  competent  and  careful  practitioner.     But,  alas 
non-union  is  too  often  due  to  carelessness,  or  want  of  skill  on  the 
part  of  the  surgeon.     Or,  the  patient  may  be  to  blame,  having  re- 
fused to  submit  to  the  necessary  restraint,  and  the  consequence 
has  been  continued  motion  in  the  part,  which  precluded  the  possi- 
bility of  ossific  union.     The  false  joint  may  be  more  or  less  per- 
fect.  Although  there  is  no  bony  union,  there  may  be  a  ligamentous. 
One  end  of  the  bones  may  be  rounded,  while  the  other  is  somewhat 
cupped.     This  is  done  by  the  absorbents,  and  is  the  necessary  pro- 
vision for  a  new  joint. 

(7aMm.— The  following  constitutional  causes  are  given-  the 
syphilitic  and  the  scrofulous  diseases,  ill  health,  pregnancy  low 
fevers,  cancerous  disease,  paralysis,  scurvy,  fragilitas  ossium,  defi- 
cient supply  of  arterial  blood,  old  age.  The  local  causes  are  fre- 
quent motion  at  the  seat  of  fracture,  non-approximation  of  the 
fractured  ends,  disease  of  the  broken  bone,  soft  tissue  intervening 
between  the  fragments,  perhaps  a  muscle,  tight  bandaging,  long 
continued  application  of  cold  water,  presence  of  an  ulcer,  a  loose 
piece  of  bone,  separation  of  the  periosteum,  too  early  use  of  the 
limb.     Two  or  more  of  these  causes  may  coexist. 

Treatment.-'Ihe  surgeon  should  always,  in  the  treatment  of 
tracture,  bear  in  mind  tlie  various  causes  which  may  lead  to  false 
joint,  and  at  all  times  watch  for  them  ;  and,  when  existing,  endea- 
vor to  remove  them,  or  prevent  their  evil  eifect.  Moreover  if 
apprehensive  of  non-union,  he  ought  by  all  means  to  apprise  the 
patient  of  the  possibility  of  the  bones  remaining  ununited.  Other- 
wise,  he  may  be  held  accountable,  and  may  even  be  chargeable 
with  malpractice. 

When  the  evil  actually  exists,  even  the  removal  of  the  cause 
may  be  followed  by  union  of  the  bone.  In  every  case,  when  the 
surgeon  finds  the  bone  ununited,  ho  should  reapply  the  splints, 
and  attack  the  cause.  If  there  has  been  too  much  motion,  endea' 
vor  to  prevent  it.  This  may  be  accomplished  by  a  starch  bandage, 
continued  for  several  months.  If  the  non-union  has  existed  for 
some  time,  and  a  false  joint  has  really  been  forme.],  uni.m  .•«  r,.^ 


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316 


PRINCIPLES    OF    SURGERY. 


likely  to  take  place,  until  the  ligamentous  substance  therein  has 
been  destroyed.  This  can  sometimes  be  done  by  rubbing  the  ends 
together  for  a  few  minutes,  before  placing  the  limb  in  splints. 
Caustic  to  the  skin  over  the  part  has  been  recommended,  also  the 
introduction  of  needles  heated,  between  the  ends,  and  also  a  seton 
may  be  employed.  Anything  to  produce  disorganization  of  the 
new  adventitious  matter  forming  the  false  joint.  Resection  may 
be  resorted  to.  Care  must  be  taken  to  remove  the  whole  of  the 
abnormal  substance  so  as  to  have  pure  bone  come  together.  There- 
after, the  limb  being  placed  in  the  proper  splint,  union  may  take 
place.  Sometimes  the  fragments  may  be  fastened  together  by 
ivory  pegs.  Sometimes  the  continued  motion,  which  prevents 
union,  is  due  to  an  unruly  muscle.  This  constantly  draws  the 
fractured  ends  apart.  In  such  cases  it  may  be  expedient  to  divide 
the  tendon  by  subcutaneous  section.  When  a  muscle  or  other  soft 
tissue  is  fixed  between  the  pieces,  it  may  likewise  be  necessary  to 
perform  resection,  not  so  much  to  remove  the  ends  of  the  frag- 
ments as  the  interposed  substance. 

Diastasis  or  Separation  of  Upiphysis.—Thia  may  happen  in 
children,  before  the  bony  structure  is  complete  or  firm.  The  child 
exposed  to  violence,  instead  of  a  fracture,  there  is  separation  of 
the  epiphysis  from  the  shaft.  It  may  also  result  from  muscular 
action.  The  diagnosis  of  this  aff'ection  is  not  always  easy,  that  is, 
from  ordinary  fracture ;  but  as  the  treatment  is  the  same  as  in 
fracture,  it  is  not  a  matter  of  essential  importance. 


CHAPTER    XXXIX. 

Surgical  Affections  of  Joints— Joints  most  liable— Inflammation— Cniisos- 
Synovitis— Symptoms— Prognosis— Pathology— Inflammation  of  outer  Tis- 
sues—Whito  Swelling- Morbus  Coxarius— Kesults. 

Surgical  Affections  of  the  Joints.— The  anatomy  and  physiol- 
ogy of  any  structure  is  essential  to  a  correct  understanding 
of  those  diseases  to  which  it  is  subject.  It  is  pre-eminently  so 
with  regard  to  the  joints.     The  bony  framework   of  the  body 


SURGICAL    AFFECTIONS    OP    JOINTS. 


317 


is  composed  of  pieces,  and  these  pieces  are  united  in  such  a  way 
as  to  allow  a  variety  of  motion  between  them.     There  is  articu- 
lation  and  motion.     Accompanying  this  there  must  be  strength, 
and  therefore  they  are  bound  together  by  strong  ligaments.     To 
facihtate  motion  between  the  ends  of  the  bones,  there  must  be 
smooth  surfaces;  this  is  secured  by  smooth  synovial  membrane. 
Then,  the  ends  have  to  be  firm,  and  at  the  same  time  yielding, 
hence  the  compact  and  elastic  cartilage  covering  the  ends  of  the 
bones.     The  arrangement  to  meet  the  above  stated  requirements 
18  most  admirable.     Entering  into  the  formation  of  the  joint  is 
the  bone  covering;  this  is  the  dense  cartilage,  which  in  turn  is 
covered  by  the  synovial  membrane.     This  membrane  is  a  closed 
sac,  hke  serous  membranes ;  yet  it  is  unlike  them,  and  the  patho- 
logical changes  incident  to  it  are  materially  different.     This  mem- 
brane  secretes  the  fluid  to  lubricate  the  joint.     Binding  together 
the  bones  are  strong  ligament!  ;  these  are  placed  outside  the  joint, 
and  cover  it,  being  lined  by  the  membrane.     Outside  the  liga- 
mentous structure,  and  in  close  connection,  are  generally  tendons 
of  muscles,  and  over  all  is  the  integument.     Now  all  these  struc- 
tures, so  diff-erent  in  character,  are,  nevertheless,  in  very  close  re- 
lationship.    Thoy  are  fed  by  the  same  vessels,  and  supplied  by 
the  same  nerves.     Consequently,  when  disease  invades  one  tissue 
It  IS  very  apt  to  extend,  by  contiguity,  as  well  as  from  nervous 
sympathy,  to  other  tissues.     Again,  every  tissue  of  the  body  may 
be  said  to  be  predisposed  to  certain  kinds  of  affections,  and  the 
tissues  entering  into  the  joint  being  numerous  and  various,  the 
joint  as  a  whole  is  exposed  to  a  large  number  of  maladies. 

The  joints  of  the  body  most  liable  to  disease,  are  those  which 
are  superficial  and  exposed  to  injury,  and  which  have  at  the  same 
time  varied  motion.  Therefore,  the  knee  is  more  frequently  the 
seat  of  disease. 

Inflammation  of  Joints.-It  may  be  idiopathic,  or  it  may  be 
symptomatic.  Its  course  may  be  acute,  subacute,  or  chronic  •  so 
quick  in  Its  action  as  to  lead  to  speedy  destruction  of  tissue,  or  so 
slow  that  It  can  scarcely  be  denominated  inflammation.  It  may 
begin  in  the  hard  structures,  or  in  the  softer.  The  most  promi- 
nent cause  of  the  disease,  will  have  to  do  in  selecting  the  particu- 
lar tissue  first  involved. 

Causes  are  constitutional  and  local     Of  the  first  are  rheuma- 


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318 


PRINCIPLES    OF    SURGERY. 


tism,  gout,  gonorrhoea,  leucorrhoea,  suppression  of  ordinary  dis- 
charge— by  metastasis,  mercurial  poison,  catheterism,  general 
debility.  The  local  causes  are  blows,  strains,  wounds,  mechanical 
injuries  of  all  kinds,  foreign  bodies  in  the  joints. 

Synovitis  in  its  various  forms  is  the  most  frequent  kind  of 
joint  disease ;  consequently,  in  speaking  of  inflammation  of  the 
joint  generally,  I  cannot  do  better  than  to  follow  the  course  of  in- 
flammation as  presented  in  this  particular  tissue. 

Inflammation  of  the  synovial  membrane  is  a  disease  of  some- 
what frequent  occurrence  in  the  adult.  It  may  be  priraarv  or 
secondary. 

Symptoms. — Pain  is  very  constant,  and  generally  very  great 
and  will  be  increased  on  motion  of  the  joint.     The  intensity  of 
the  pain  will,  to  some  extent,  indicate  the  acuteness  of  the  disease. 
Swelling  takes  place  early,  and  may  be  due  to  effusion  into  the 
joint,  or  into  the  circumjacent  tissue, "or  perhaps  in  both.    Redness 
is  not  present  at  first,  but  is  in  the  later  stages  of  the  disease. 
Meat  is  usually  present.    All  of  these  symptoms  are  better  marked 
at  night,  and  cause  restlessness  and  constitutional  disturbance. 
But  the  most  characteristic  symptom  of  this  disease  is  the  fixed 
position  in  which  the  joint  is  placed.     The  reason  of  this  is  obvi- 
ous.    The  slightest  motion  in  the  joint  intensifies  the  pain ;  the 
inflamed  synovial  membrane  is  at  such  times  exposed  to  pressure 
between  the  ends  of  the  hard  bones.    This  acute  pain  begets  sym- 
pathy in  the  muscles  related  to  the  part,  and  they  at  once  begin 
to  contract — contract  firmly,  the  whole  of  them,  around  the  joint, 
flexors,  and  extensors.    The  consequence  is,  the  joint  is  fixed,  and 
(what  is  important  to  note)  this  rigid  state  of  the  muscles  tends  to 
increase^at  least  to  continue,  the  pressure  upon  the  sensitive  mem- 
brane.    But  some  of  the  muscles  around  every  joint  are  more 
powerful  than  others,  and  their  rigidity  is  more  incessant.    In 
consequence  of  this,  the  limb  will  become  gradually  flexed— a 
phenomenon  often  witnessed  in  inflammation  of  the  knee-joint. 
This  takes  place  so  slowly,  that  it  may  not  be  discernible  from 
day  to  day,  but  only  when  several  days  of  interval  are  considered. 
On  this  subject,  I  am  much  indebted  to  the  teachings  of  Hilton. 

Diagnosis, — It  is  not  difficult  to  diagnose  inflammation  of  the 
joint,  but  it  may  be  to  distinguish  synovitis  from  inflammaliou  of 
other  tissues  in  the  joint.    This,  however,  is  not  important,  so  far 


SURGICAL    AFFECTIONS    OF    JOINTS.  319 

as  the  treatment  is  concerned.     To  detect  effusion  into  the  joint 
which  results  from  synovitis,  the  surgeon  will  be  assisted  by  con- 
sidering  the  form  which  the  joint  presents.     Remembering  the 
situation  of  those  points  where  the  membrane  approaches  to  the 
surface  of  the  limb,  and  which  are  not  covered  by  any  unyielding 
tissue,  It  will  be  expected  there  to  find  unusual  prominence  or 
fulness,  from  the  fluid  pressing  outward.     The  presence  of  fluid 
m  the  joint  would  not  alone  prove  the  existence  of  the  inflamma- 
tion,  inasmuch  as  dropsy  of  the  joint  may  result  from  other  causes. 
It  IS,  however,  a  valuable  diagnostic  mark  when  other  symptoms  of 
recent  inflammation  are  present.     The  sensation  of  fluctuation 
about  the  joint  is  often  deceptive.     More  than  one  accomplished 
surgeon  has  made  an  incision  over  a  joint,  expecting  to  find  fluid 
but  who  found  none.     The  feeling  of  fluctuation  is  due  to  effusion 
of  serum  into  the  cellular  or  adipose  tissue  external  to  the  cavity 
of  the  joint.  ^ 

Prognosis.-Thk  should  always  be  guarded.  Sometimes,  under 
the  most  careful  treatment,  in  spite  of  everything,  the  inflamma- 
tory disease  gradually  merges  into  some  species  of  degeneration 
or  ulcerative  destruction  of  one  or  more  of  the  tissues,  and  results 
in  the  loss  of  the  joint.  The  opinion  will  be  more  unfavorable 
when  there  is  a  predisposing  constitutional  cause. 

Pathology.— In  connection  with  synovitis,  it  will  be  advisable  to 
discuss  the  various  products  of  the  disease.  Various  forms  of  sy- 
novitis  have  been  described  by  Brodie  and  others.  Several  divi- 
sions  of  inflammation  and  degeneration  have  been  given  by  writers 
This  multiplicity,  perhaps,  tends  to  confuse  the  student,  without 
conferring  any  commensurate  advantage.  My  object  always  is 
to  simplify  as  much  as  possible,  while  I  make  plain  that  which  is 
essential. 

Synovitis  proper  is  attended  and  followed  by  the  ordinary  pro- 
ducts of  inflammation.  The  joint  is  intended  for  motion ;  and 
although  the  synovial  membrane  lining  it  so  closely  resembles  the 
serous  membrane  anatomically  and  physiologically,  there  is  this 
important  difference  pathologically:  when  fibrin  is  poured  out 
upon  Its  surface,  as  a  result  of  inflammation,  instead  of  its  display- 
ing a  tendency  to  organize,  as  it  does  upon  a  serous  membrane,  it 
shows  a  disposition  to  degenerate  into  pus.  The  lymph  is  more 
corpuscular  than  fibrinous.     At  the  same  time,  the  occasional  mo- 


1  r>\ 


i       '    !  ^  1 1 


i    A 


I 


320 


PRINCIPLES    OF    SURGERT. 


tion  of  the  joint  prevents  the  existence  of  the  condition  necessary 
to  allow  adhesion.  Here  is  manifested  an  admirable  provision  of 
nature.  The  joint  is  for  motion,  and  nature  takes  care  that,  even 
in  disease,  this  sole  function  shall  not  be  jeopardized.  The  forma- 
tion of  pus  is  undoubtedly  a  serious  result ;  yet  it  would  seem  that 
the  requirements  of  man  are  such,  that  it  were  better  to  have  pus 
formed  in  the  joint,  which  may  be  discharged  without  necessarily 
destroying  the  joint,  than  that  the  joint  should  be  impaired  or  de- 
stroyed by  adhesive  inflammation. 

It  is,  however,  only  when  the  inflammation  is  acute  that  the  re- 
sulting fibrin  is  likely  to  degenerate  into  pus.     When  this  action 
is  subacute  or  chronic,  other  results  follow,  no  less  serious  and 
destructive.     The  congestion,  ipore  passive  than  active,  leads  to 
eff"usion  of  liquor  sanguinis  (with  a  large  proportion  of  serum) 
into  the  sac,  or  into  the  substance  of  the  membrane  and  the  adja- 
cent tissue.      The  inflammation  may  at  first  have  been  acute 
during  which  lymph  had  been  effused  upon  the  free  surface  of  the 
membrane ;  subsequently,  the  inflammation  becoming  less  active, 
liquor  sanguinis  is  poured  out,  with  a  larger  quantity  of  serum,  and 
with  lymph  possessed  of  a  low  standard  of  vitality.    This  process  of 
asthenic  disease,  with  deposition  of  imperfect  fibrin,  may  continue 
for  an  indefinite  time,  and  the  fibrin  all  the  time  undergoing  a 
species  of  degeneration,  and  terminating  by  affecti^ig  the  vitality 
of  the  tissue  in  which  it  is  deposited.     Thus,  the  membrane  may 
be  gradually  thickened  and  softened  to  a  very  great  extent.     The 
lymph  does  not  always  at  once  degenerate,  either  into  pus  or  in  any 
other  way.     It  sometimes  will  remain  for  a  time  in  a  semi-organ- 
ized state,  and  thereafter  begin  to  decline  in  vitality,  and  finally 
to  perish.     Soiuetimes  it  will  be  seen  floating  in  flakes  in  the 
cavity  of  the  joint.     On  the  other  hand,  occasionally,  the  adven- 
titious substance  will  undergo  a  form  of  organization  upon  the 
membrane,  something  like  granulations.     The  result  will  be,  nu- 
merous villous  processes  with  fringed  borders.  (System  of  Surgery.) 
When  the  synovial  membrane  becomes  thickened  and  soft,  in 
the  manner  above  described,  it  is  commonly  known  by  the  term  of 
"white  swelling."     It  is  not  only  soft,  but  it  is  often  pulpy  and 
gelatinous.     The  thickening  is  often  very  great,  sometimes  even 
to  a  quarter  or  half  an  inch,  or  even  an  inch.     The  fluid  within 
the  joint,  and  the  membrane  itself,  presents  sometimes  one  color, 


none  exist  in 


SURGICAL    APPEOTIONS    OF    JOINTS.  321 

sometimes  another,  there  being  quite  a  variety:  sometimes  a  light 
brown,  or  a  reddish  hue.  ^ 

We  have  seen  that  synovitis  may  be  acute,  or  it  may  be  very 
chronic,  but  that  no  line  of  separation  can  be  drawn  between 
moreover,  that  the  acute  may  become  chronic;  and  finally,  that  il 
may  degenerate  into  a  disease  which  cannot  be  said  to  possess  any 
feature  of  mflammation.     But  in  all  these  varieties,  the  adjacent 
tissues  are  equally  exposed  to  danger.     The  cartilage,  so  closely 
united  to  the  synovial  membrane,  will  soon  suffer,  and  begin  to 
disappear  by  a  process  of  ulceration.     The  bone,  being  in  imme- 
diate  relationship  with  the  cartilage,  cannot  remain  unaffected. 
In  the  acute  disease,  the  bone  will  soon  become  congested;  while 
in  the  chronic  the  slow-paced  disease,  it  will  gradually  undergo  a 
process  of  softening,  and  at  last  become,  perhaps,  carious.    Then 
the  fibrous  tissue  around  the  joint-that  is,  the  ligaments  and  ten' 
dons  of  muscles-may  be  expected  to  participate  in  the  morbid 
action  going  on  within.     In  the  acute  form,  when  pus  speedily 
forms,  the  surgeon  may  expect  to  see  the  same  phenomena  as  is 
witnessed  m  the  progress  of  an  ordinary  abscess. 
^  These  ordinary  features  in  the  pathology  of  disease  in  the  syno- 
vial  membrane  will  always  be  modified  by  any  peculiar  constitu-  " 
tional   disease   which  may  have  been  their  predisposing  cause. 
Thus,  If  there  be  scrofula,  the  characteristics  of  that  affection  will 
be  prominent,  and  the  products  will  be  materially  modified  thereby. 
Also,  If  syphilis  exist  in  the  constitution,  or  any  other  special  dis- 
ease,  it  will  give  character  to  the  local  malady.    But,  for  a  know- 
ledge  of  these,  the  reader  is  requested  to  turn  to  those  diseases. 

Sometimes  inflammation,  and  other  diseases  of  the  joint,  com- 
mences in  the  textures  adjacent  to  the  synovial  membrane  and 
the  synovial  thickening  and  softening  is  a  result  of  that.     We 
have  learned  that  disease  often  arises  in  the  bone,  and,  it  may  be 
m  the  ends  of  the  bones.     From  the  bone,  it  may  gradually  ex^ 
tend  until  the  synovial  membrane  is  involved,  as  in  the  manner 
above  described.     Or,  the  disease  may  originate  in  the  cartilage, 
or  in  the  ligaments,  or  from  some  injury  external  to  the  joint   ' 
which  will  lead  to  similar  results.     But,  respecting  the  cartilage 
t  canno   be  properly  said  that  it  is  subject  to  inflammation.     Fo^ 
the  development  of  inflammation,  bloodvessels  are  necessary,  but 
none  exist  in  the  cartilage.     In  it  the  process  of  nutrition  is  car- 

21 


li^i! 


i!' 


I  ">i 


I       HU 


322 


PRINCIPLES    OF    SURGERY. 


ried  on  through  the  agency  of  cells ;  consequently,  true  inflamma- 
tory action  is  impossible.  But  this  anatomical  condition  accounts 
.for  the  fact  that  the  cartilage  is  liable  to  sufier  when  any  disease 
exists  in  the  neighboring  tissues.  If  the  supply  of  blood  which 
comes  to  the  cartilage,  although  it  does  not  enter,  be  limited  or 
cut  off,  the  vitality  of  that  structure  is  at  once  attacked,  and  ul- 
cerative destruction  will  probably  ensue.  If  inflammation  or  other 
disease  involves  those  feeding-vessels,  in  like  manner  the  cartilage 
will  be  exposed  to  danger.  But,  although  the  absence  of  blood- 
vessels will  not  allow  ordinary  inflammation,  there  is  nevertheless 
a  morbid  action,  which  is  the  result  of  the  adjacent  disease.  The 
cartilage  may  become  thickened  or  softened,  or  it  may  degenerate 
or  ossify,  or  ulcerate,  or  actually  perish. 

There  are  two  notable  diseases  which  belong  to  the  joint :  white 
swelling,  and  morbus  coxarius.  In  the  former,  which  is  peculiar 
to  the  knee-joint,  the  synovial  membrane  is  principally,  at  least 
primarily,  involved.  In  the  latter,  a  disease  of  the  hip-joint,  the 
cartilage  is  principally  concerned,  and  it  is  said  it  commonly  ori- 
ginates in  that  tissue.  Certainly,  the  cartilage  is  destroyed  at  an 
early  stage  of  the  disease. 

Inflammation  and  other  diseases  sometimes  arise  in  the  outer 
tissues,  of  the  joint,  as  the  ligaments,  the  tendons  of  muscles,  the 
cellular  tissue,  and  the  skin ;  thence  extending  to  the  bone,  or  to 
the  cartilage,  or  the  synovial  membrane.  The  ligaments  may 
become  elongated,  or  the  muscles  contracted,  as  above  explained, 
and  the  integument  thickened  and  discolored ;  or,  on  the  contrary, 
it  may  be  preternaturally  white,  as  in  the  white  swelling.  Again, 
as  will  be  at  once  understood,  abscesses  may  form — indeed,  are 
very  sure  to  form,  if  the  disease  progresses.  Openings  result,  and 
chronic  sinuses. 

Results. — Of  course,  at  any  time  during  the  progress  of  inflam- 
mation, the  cause  of  the  morbid  action  may  be  removed.  Then, 
if  changes  too  important  have  not  taken  place,  resolution  may 
follow ;  but  if  serious  destruction  has  occurred,  or  morbid  changes 
been  effected,  then,  although  the  disease  may  be  stayed,  a  cure 
cannot  be  expected  at  once  to  follow.  The  joint  will  consequently 
be  impaired,  or  entirely  destroyed,  anchylosis  being  the  result. 
When  the  motion  of  the  joint  is  only  impaired  by  morbid  deposits, 
or  by  contracted  tendons,  under  judicious  management  the  motion 


SYNOVIIIS— TKEATMBHT.  323 

8ults,-there  be.ng  permanent  union  between  the  ends  of  the 
bone,  o».fie  or  l,gan.ento„s,-of  oonrse,  restoration  t  t^ 

re.o.a  b,  ^»seetion:;a^;li::,— ^^^^^^^^^^ 


i+i 


CHAPTEB    XL. 

Treatment:  Reet-AppIioation^ExeWoi.. 

rrea(™e»(._This  will,  to  some  extent,  depend  nponthe  eanse  of 

s  called  to  treat  >t.     When  the  inflammation  is  running  high  th,. 

treatment  must  be  correspondingly  active.     One  of  the  firsf  IndY 

cafons  .s  to  maintain  the  limb  in  a  state  of  absolute  repose    I  " 

he  body  and  mmd  should  be  in  a  state  of  rest.    We  h  ';  seen 

the  jomt  by  the  aid  of  continued  muscular  contraction.  But  thif 
mcessant  pressure  upon  inflamed  tissue  cannot  but  be  provocatTve 
0  further  ir„t.t,on,  and  it  is  therefore  in  itself  an  evil  Now  bv 
lacng  the  l,mb  in  a  comfortable  position,  in  the  first  stage  of'the 
d.,ease,  pajn  w.ll  be  allayed,  and  the  inflammation  stayef  a  he 
muscles  w,ll  then  cease  to  act;  but  the  limb,  exposed  to  mot  on 

fonable  mode  of  obtaming  rest.     Then,  the  muscles  being  of 
unequal  strength  the  joint  will  gradually  be  changed  in  pos"fion 
To  what  extent  this  slow  flexion  of  an  inflamed  joint  may  prove 
disastrous  IS  well  exemplified  in  the  knee-joint,  in  many  caserif 
art,cu  ar  rheumatism.    If  the  limb  could  I  placed  aHhefi       in 
a  pos,t,on  of  rest,  the  muscles  would  not  th„r  contract,  and  such 
serious  pathological  results  would  not  follow 
The  treatment  will  always  divide  itself  into  general  «„d  !„„., 


f'   ''"i%f 


I  ;: 


324 


PRINCIPLES    OP    SURGERY. 


So  far  as  the  formbi'  is  concerned,  it  need  only  be  said  here  that  it 
is  based  on  the  general  principles  of  inflammation,  and  will  be 
particularly  directed  to  any  constitutional  taint  that  may  have 
been  the  cause  of  the  disease. 

As  to  the  local  treatment,  the  limb  having  been  placed  in  the 
position  abov£  indicated,  endeavors  will  be  made  to  alleviate  and 
remove  the  pain,  as  it  is  the  principal  link  in  the  chain  of  morbid 
events.  "  The  same  trunks  of  nerves  whose  branches  supply  the 
groups  of  muscles  moving  a  joint,  furnish  also  a  distribution  of 

nerves  to  the  skin  over  the  insertions  of  the  same  muscles ;  and 

what  at  this  moment  more  especially  merits  our  attention — the  in- 
terior of  the  joint  receives  its  nerves  from  the  same  source." 
(Hilton.)     Such  being  the  case,  it  can  be  at  once  understood  that 
the  irritated  nerves  within  the  joint  may  be  reached  through  those 
nerves  which  are  placed  external  to  it.     Hence  it  is  that  soothing 
applications  are  so  generally  serviceable.     Hot  fomentations,  or 
poultices,  in  the  first  stage  of  inflammation,  are  most  valuable,  and 
will,  in  conjunction  with  rest  of  the  limb,  be  in  many  cases  ade- 
quate to  an  est  the  disease.     Anodynes,  alone,  or  with  the  hot 
applications,  are  also  useful.     Indeed,  all  those  agents  which  have 
been  given  in  the  treatment  of  inflammation  may  prove  beneficial. 
I  have  found  a  solution  of  Plumbi  Acet.  most  valuable ;  but  it  re- 
quires to  be  strong,  and  diligently  applied.    Repeated  local  bleed- 
ing by  leeches  will  often  be  necessary.     If,  in  the  course  of  the 
disease,  pus  is  believed  to  exist,  either  in  the  joint  or  in  the  tissue 
external  thereto,  it  should  be  promptly  evacuated  by  the  use  of 
the  knife.     The  theory  is  well-nigh  exploded  that  it  is  necessarily 
most  disastrous  to  open  a  joint,  either  in  health  or  disease ;  but 
even  were  it  true  that  the  exposure  of  the  interior  of  a  joint  to 
the  air  would  lead  to  evil  consequences,  yet,  of  two  dangers,  it 
would  be  far  less  than  to  allow  pus  to  remain  pent  up,  which,  by 
its   presence  and   pressure,    would    produce    disorganization   of 
tissue. 

When  the  acute  symptoms  have  subsided,  and  there  be  effusion, 
other  than  of  pus,  in  the  joint,  and  also  when  the  action  has  as- 
sumed the  chronic  form,  the  application  of  blisters  is  indicated. 
The)'  ought  not  to  be  very  large,  but  repeated,  first  on  one  side 
and  then  on  the  other.  At  this  stage  of  the  disease  hot  fomenta- 
tions and  poultices  ought  not  to  be  employed,  unless  severe  pain 


SYNOVITIS  — TREATMENT. 


325 


render  it  necessary,  and  then  their  use  must  be  only  temporary. 
I  have  often  seen  their  continuance  lead  to  disastrous  results.  In 
the  first  stage,  they  relaxed  the  tissue,  and  soothed  the  irritated 
nerves;  but,  being  continued  too  long,  they  induced  passive  con- 
gestion,  and  thus  prevented  a  return  of  the  vessels  to  their  natural 
tone,  and  a  restoration  to  physiological  action  of  the  parts  involved 
in  disease.  There  is  at  this  time  a  tendency  to  venous  congestion 
not  alone  of  the  knee,  but  the  leg  and  foot.  An  elevated  position 
of  the  limb  will,  to  some  extent,  counteract  this  tendency.  Leeches 
will  relieve  the  local  passive  congestion  as  well  as  the  active. 

When  the  disease  assumes  the  form  of  thickening,  and  of  de- 
generation of  the  membrane— when  there  is,  for  instance,  «  white 
swelling,"  the  treatment  will  be  primarily  directed  to  the  consti- 
tution  ;  the  local  treatment  will  have  to  be  long  continued.  Coun- 
ter-irritation by  issue  or  by  repeated  blisters,  will  divert  morbid 
nature  from  the  seat  of  disease,  whereby  a  physiological  action 
may  become  possible.  A  very  important  element  in  the  treatment 
18  well-directed  pressure  upon  the  joint  by  straps  or  by  bandage 
Should  acute  symptoms  at  any  time  present  themselves;  they  must 
be  met  by  appropriate  treatment.  Rest-protracted  rest,  and  ex- 
tendmg  over  a  period  of  months,  perhaps  years,  will  generally  be 
demanded  ;  but,  at  the  same  time,  fresh  air  and  a  change  of  life 
are  highly  essential  to  the  restoration  of  the  general  health' 
While  these  are  secured,  rest  of  the  joint  may  be  also  obtained  bv 
the  skilful  use  of  straps,  or  by  a  sling  or  a  crutch,  so  arranged  that 
motion  of  the  joint  is  effectually  prevented. 

When  the  process  of  repair  is  well  under  progress,  some  atten- 
tion should  be  paid  to  the  preserving  of  the  joint.  The  patient 
cannot  be  allowed  to  use  the  joint,  but  the  surgeon  should,  from 
time  to  time,  employ  passive  motion,  always  being  careful  not  to 
disturb  the  work  of  repair,  as  it  would  be  better  to  have  anchylo- 
818  than  to  place  the  limb  or  the  life  in  jeopardy. 

Sometimes  the  tissues,  one  or  more,  'are  so  disorganized,  or  de- 
stroyed  by  ulceration,  that  the  patient  must  needs  keep  to  his  bed 
In  such  cases  suitable  splints  will  have  to  be  applied  to  the  limb 
so  as  to  give  it  support.  It  has  already  been  said  that  wiien  pus 
18  found  to  exist  in  the  joint,  it  must  be  treated  as  in  abscess;  but 
It  will  often  occur,  that  from  some  reason,  such  treatment  has  not 
been  pursued,  and  the  pu»,  thus  remaining  pent  up,  has  caused  a 


n 


A 


!    IbGi 


'I        ^^\ 


326 


PRINCIPLES    OF    SURGERY. 


very  serious  amount  of  ulcerative  destruction,  involving  the  mem- 
brane, the  cartilage,  and  even  the  bone.  Whatever  may  have  been 
the  immediate  cause  of  the  ulcerative  destruction,  when  the  joint 
is  thus  seriously  involved,  it  will  be  a  question  whether  restoration 
may  possibly  be  effected,  even  with  anchylosis,  or  whether  removal 
of  the  diseased  bone,  by  either  excision  or  amputation,  will  have 
to  be  resorted  to.  If  the  disease  is  evidently  progressing,  or  con- 
tinues for  a  long  time  without  any  signs  of  amelioration,  notwith- 
standing all  treatment,  there  can  be  no  doubt  as  to  the  propriety 
of  operation.  The  continued  disease  will  materially  affect  the 
general  health,  and  sooner  or  later  the  powers  of  life  will  suc- 
cumb. 

The  practice  of  excisiftg  joints  is  of  a  comparatively  recent  date 
and  perhaps  there  does  not  yet  exist  sufficient  data  upon  which  to 
base  a  correct  estimate  of  its  value.  No  one  can  question  the 
general  principle  that,  in  operating,  no  more  of  a  limb  should  be 
removed  than  is  really  necessary.  Applying  this  rule  to  the  mat- 
ter under  consideration,  it  seems  plain  that  excision  ought,  when- 
ever possible,  to  take  the  place  of  amputation.  To  many,  a  natural 
limb,  even  with  an  anchylosed  joint,  is  preferable  to  a  false  one. 
The  position  of  the  patient  in  life  will,  to  some  extent,  be  taken 
into  consider;  tion,  as  well  as  his  avowed  wishes  on  the  subject. 
The  question  of  mortality  after  this  operation,  when  compared 
with  the  hazard  attending  amputation,  will  also  have  to  be  weighed. 
On  this  point  perhaps  there  may  bo  a  difference  of  opinion. 

I  enjoyed  the  high  privilege  while  in  London,  in  1856,  of  seeing 
the  eminent  Fergusson  (to  whom  the  surgical  profession  is  so  much 
indebted),  perform  excision  of  the  knee  joint,  and  heard  him  ex- 
pound  the  principles  upon  which  he  based  his  procedure.     He  pre- 
sented to  his  students  and  listeners  several  cases  upon  whom  he 
had  previously  operated,  all  of  whom  had  had  most  encouraging 
recoveries.     The  lesson  I  have  never  forgotten,  nor  have  I  ever 
doubted  the  importance  of  the  operation,  or  the  value  of  resection 
of  the  joint,  whatever  may  have  been  the  cause  of  disease.     I  have 
seen  cases  of  resection  which  ultimately  failed,  but  I  was  not  con- 
vinced that  the  failure  ivaa  not  due  to  the  treatment  pursued  subse- 
quent to  the  operation.    The  resuits  of  the  operation  are  sonii'limcH 
surprising.     Nature,  rid  of  the  diseased  structure,  which  she  had 
fruitlessly  striven  to  repair,  rallies  again  to  the  work ;  and  often 


SYNOVITIS  — TREATMENT. 


327 


in  a  short  time,  the  limb  will  become  to  some  extent  restored,  at 
least  the  general  health  is  improved.  Fergusson  has  recorded  not 
a  few  cases  where,  at  the  time  of  operation,  there  was  great  ema- 
ciation and  prostration,  but  immediately  thereafter  the  strength 
began  to  increase,  the  general  health  to  improve. 

Upon  one  or  two  points  I  wish  still  further  to  speak  in  connec- 
tion  with  the  subject  of  resection,  inasmuch  as  they  are  not  very 
well  established.  Many  of  the  profession  seem  slow  to  believe  that 
m  performing  excision  the  joint  is  not  necessarily  lost— that  a  new 
one  may,  and  will  he  created  if  proper  treatment  be  pursued.  It  is 
the  more  common  belief  that  the  most  to  be  hoped  for,  is  an  ossific 
and  firm  union  between  the  ends  of  the  bones.  And  every  step 
which  is  taken  subsequent  to  the  operation,  is  bent  to  secure  this 
union  between  the  two  bones.  After  the  ends  have  been  sawed 
off,  the  bones  are  brought  together,  perhaps  fastened  by  metallic 
sutures ;  ev  ^ry  effort  is  made  to  prevent  motion,  the  same  as  after 
fracture.  In  some  cases  this  may  be  the  most  promising  procedure, 
hut  the  higher  aim  of  the  surgeon  is  to  ohtain  a  false  joint. 

It  has  been  seen  {vide  False  Joints)  that  occasionally  after 
fracture,  union  does  not  take  place;  and  that  one  unpleasant  cause 
of  this  is  continued  motion  at  the  seat  of  fracture.  Well,  there 
can  be  no  reason  why  the  same  result  shall  not  follow  resection  of 
a  joint.  Indeed,  the  condition  of  the  parts  is  favorable  to  this ; 
the  action  of  the  muscles  by  which  the  limb  is  naturally  moved,' 
will  produce  that  active  motion  necessary  to  the  formation  of  a 
new  joint.  Cases  are  recorded  by  Hancock  and  others,  in  which 
a  very  complete  joint  was  formed  after  an  entire  removal  of  the 
natural  joint.  And  what  has  taken  place  can  again  take  place, 
not  in  certain  joints,  but  in  all. 

Another  point  to  which  I  wish  to  refer  is,  that  with  the  joint 
there  may  be  also  the  formation  of  a  largo  quantity  of  new  bone. 
Much  of  the  bone,  from  those  entering  into  the  formation  of  the 
joint,  may  be  excised,  and  subsequently  restored  before  the  joint  is 
re-formed. 

To  illustrate  these  points,  I  will  introduce  the  record  of  a  case 
which  I  furnished  to  the  London  "Lancet."  The  importance  of 
the  principles  under  consideration  is  a  sufficient  excuse  for  intro- 
ducing it  here. 


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328 


PRINCIPLES    OF    SURGERY. 


EESECTION  OF  THE  ANKLE-JOINT. 

To  THE  Editor  op  the  Lancet. 

Sir:  I  had  the  honor  to  report  in  the  " British  American  Jour 
nal  m  the  June  number  of  1862,  a  case  of  "Resection  of  the 
Ankle-Jomt.  The  case  was  recorded  four  months  after  the  one 
ration  I  then  stated  that  I  should  at  the  expiration  of  a  year 
furnish  the  profession  with  the  final  result.  The  journal  in  which 
the  case  was  published  has  ceased  to  exist.  I  therefore  take  the 
liberty  of  requesting  a  space  in  the  "Lancet"  to  fulfil  my  nro 
mise.  Indeed  I  venture  to  think  the  case  of  sufficient  importance 
to  warrant  its  publication  in  your  widely  circulated  journal 

There  are  two  or  three  points  to  which  I  purpose  particularly 
to  refer,  and  which  will  become  apparent  as  I  proceed.     These  are 
pomts  regarding  which  there  is  at  the  present  time  pe-'haps  no 
settled  opinion.     The  operation  was  performed  in  the  way  recora 
mended  by  Henry  Hancock,  Esq.,  surgeon  to  the  Charing  Cross 
Hospital.     Last  winter  Mr.  Hancock,  in  urging  the  importance  of 
this  operation,  referred  to  the  success  which  had  attended  the  case 
under  consideration,  and  I  think  from  it  it  will  be  seen  that  con- 
servative surgery  deserves  to  be  more  fully  tested.     The  young 
man  operated  upon  was  twenty-one  years  of  age,  with  a  constitu- 
tion  m  most  respects  good.     The  disease  of  the  hones  which  led 
to  the  operation  was,  I  think,  chiefly,  if  not  altogether,  due  to 
local  causes.     Having  made  the  single  incision  through  the  inte- 
gument  as  recommended,  and  dissected  up  the  flap,  the  following 
pieces  of  bone  were  successively  removed :  first,  the  astragalus 
one-half  of  which  was  in  a  state  of  necrosis,  and  the  other  portion 
in  a  disorganized  condition.     Then  the  external  malleolus,  after 
which  the  tibia  was  turned  out,  and  a  little  more  than  half  an  inch 
sawn  off;  but  the  condition  of  the  bones  above  was  such  that  it 
was  deemed  necessary  to  remove  more  ;  consequently,  the  incision 
through  the  soft  parts  having  been  extended,  and  the  parts  dis- 
sected from  the  bone,  an  inch  and  a  half  more  of  both  tibia  and 
fibula  were  removed.     At  this  time  it  was  recommended  by  the 
surgeon  assisting  me  to  amputate ;  but  as  I  ha.l  strong  faith  in 
Nature's  ability  to  heal,  and  as  the  patient  had  caused  me  to  pro- 
mise that  If  there  was  but  a  slight  possibility  of  saving  the  foot  to 
give  him  the  benefit  of  it,  I  determined  to  make  the  trial.     The 


RESECTION    OP    THE    ANKLE-JOINT. 


329 


upper  surface  of  the  os  calcis  was  thereafter  also  removed  to  the 
extent  of  half  an  inch  by  the  gouge.     The  operation  being  com- 
pleted, the  limb  was  placed  in  the  fracture-box.     By  careful  mea- 
surement of  the  bones  excised,  it  was  found  that  fully  three  inches 
in  length  had  been  removed.     The  space,  however,  between  the 
bones  of  the  foot  and  those  of  the  leg  was  perceptibly  diminished 
by  contraction  of  the  muscles  of  the  leg.     I  confess  my  anxiety 
was  great  to  see  the  result,  for  I  was  not  aware  of  any  precedent 
for  so  extensive  a  removal  of  bone.     But  no  artery  of  any  size 
had  been  divided  in  the  operation;  the  diseased  bone  had  been 
completely  removed,  and  I  trusted  that  the  powers  of  Nature  would 
prove  adequate  to  the  task  of  repair,  although  so  extensive.     A 
portion  of  the  flap,  in  which  was  a  cicatrix  that  had  resulted  from 
previous  sloughing,  subsequently  perished,  leaving  a  large  open- 
ing, through  which  could  be  seen  the  end  of  the  tibia.     But,  not- 
withstanding this  increased  work  of  repair,  healing  of  the  whole 
rapidly  progressed.     There  was  no  great  discharge  at  any  time, 
no  inflammation,  no  waste  of  reparative  material.     Water-dressing 
alone  was  used.     I  mention  these  facts,  because  had  there  been 
uTitation,  had  there  been  much  discharge,  the  result  might  not 
have  ^een  so  favorable. 

At  the  end  of  nine  weoks  the  limb  presented  the  following  ap- 
pearance:  A  healthy-looking  and  limited  cicatrix,  marking  the 
incision  through  the  integument.  A  very  small  opening  internally, 
where  had  been  the  most  sloughing.  The  foot  reduced  to  almost 
its  natural  size,  and  in  a  natural  position.  The  bones  of  the  foot 
have  not  yet  joined  with  those  of  the  leg.  The  foot  can  be  moved 
passively  m  any  direction,  yet  there  is  a  comfortable  degree  of 
firmness,  which  has  been  constantly  increasing.  The  patient  can 
move  the  foot  and  toes  in  a  natural  manner.  In  a  word,  there  is 
a  prospect  of  an  excellent  joint. 

Within  four  montlis  after  the  operation  ho  could  rest  the  foot 
upon  the  ground;  within  six  months  he  could  walk  by  the  aid  of 
a  cane,  and  at  the  expiration  of  a  year  he  could  run  upon  it.  I 
saw  him  on  one  occasion  mount  a  flight  of  stairs  three  steps  at  a 
leap.  I  have  recently  seen  the  patient,  and  found  by  measure- 
ment that  there  is  just  two  inches  of  shortening.  A  boot  is  worn, 
with  a  sole  thickened  about  three  quarters  of  an  inch.     The  ankle 


mil 


•■■J       •:! 


330 


PRINCIPLES    OP    SURGERY. 


is  supported  on  either  side  by  steel  springs,  and  he  walks  with  a 
very  slight  limp. 

Now,  in  this  case  we  have  a  very  striking  exemplification  of  the 
resources  of  Nature.     Not  only  is  there  an  extraordinary  restora- 
tion of  bone,  but  there  has  also  been  the  formation  of  a  new  joint. 
In  order  to  prevent  an  ossific  union  between  the  bones  of  the  foot 
and  those  of  the  leg,  the  patient  was  instructed  at  an  early  date 
to  exercise  the  muscles  of  the  leg,  so  as  to  cause  active  motion. 
The  result  now  is  a  very  perfect  joint.     Not  a  few  medical  friends,' 
with  whom  I  have  conversed  about  it,  cannot  credit  the  fact  that 
there  is  any  motion,  being  led  away  with  the  belief  that  after  ex- 
cision of  a  joint  there  is  necessarily  a  stiff  joint.     I  have  reminded 
such  that  a  very  common  cause  of  false  joint  after  fracture  is  con- 
tinned  motion  at  the  seat  of  fracture ;  and  if  so  unfortunate  a  re- 
sult follows  so  simple  a  cause,  in  connection  with  a  fracture  badly 
treated,  why  can  we  not  secure  the  same  result  after  excision  of  a 
joint,  by  which  the  natural  motion  and  use  of  the  limb  will  be  re- 
tained ?     This,  as  I  have  before  said,  can  be  secured  by  causing 
the  patient  to  use  the  muscles,  so  as  to  keep  up  motion.     One  can 
only  speculate  with  regard  to  the  provisions  of  this  new  joint,  and 
it  would  be  interesting  and  instructive  to  examine  it ;  but  in  this 
case  I  do  not  think  a  chance  will  offer  as  long  as  tlie  patient  lives. 


CHAPTER   XL  I. 

Dropsy  of  Joints :  Causes— Treatment.  Elongation  of  Ligaments.  Cartilage 
in  Joint:  Diagnosis— Prognosis— Treatment.  Wounds  of  Joints:  Ding- 
nosis— Treatment.  Deformities  of  the  Joints:  Varieties— Congenital— 
Non-congenital- Treatment. 


Dropsy  of  the  Joint;  Hydrops  ^/•<iCM?e.— Sometimes  swelling 
of  a  joint  will  take  place  in  such  an  insidious  manner,  that  the 
patient  will  not  be  aware  of  it  until  the  enlargement  has  become 
considerable.  There  is  an  entire  absence  of  pain,  or  other  symp- 
toms  which  would  attract  his  attention.     There  may  be  a  degree 


DROPSY    OF    JOINTS. 


331 


of  weakness  in  the  joint,  but  it  is  more  often  the  result  of  the 
dropsy  than  an  early  symptom.  There  seems  to  be  a  greater 
activity  m  the  secreting  function  than  in  the  absorbents.  The 
former  may  be  increased,  or  the  latter  may  be  diminished. 

PrediBposing  OauBe.—This  may  be  some  general  debility  of  the 
system,  or  a  local  injury  whereby  the  integrity  of  the  joint  was 
impaired. 

Some  slight  injury  may  constitute  an  immediate  came,  but  fre- 
quently none  is  perceptible. 

Treatment,  in  the  main,  will  consist  in  the  administration  of 
some  preparation  of  iodine  and  iron.    Local  applications  of  the 
tincture  of  iodine,  or  a  large  blister  over  the  joint,  or  croton  oil, 
may  be  used.     When  these  fail,  puncturing  the  joint  may  be  re- 
sorted  to;  and  after  the  fluid  has  been  drawn  off,  the  cavity  may 
be  injected  with  tincture  of  iodine,  reduced  one-half  with  water. 
Of  late  years,  the  practice  of  injecting  tincture  of  iodine  into 
closed  cavities  has  been  successfully  followed;  into  joints,  as  well 
as  into  serous  sacs.      I  remember  to  have  seen  the  renowned 
Velpeau,  in  the  Hdpital  de  la  Ohariti,  inject  a  quantity  of  the 
tincture  of  iodine  into  the  peritoneal  cavity,  after  a  quantity  of 
fluid  had  been  removed.     At  this  I  was  more  than  astonished,  and 
expected  to  see,  on  the  following  morning,  inflammation  of  an 
active  nature;  but  there  was  nothing  of  the  kind,  and  the  patient 
did  well.     The  chronic  ascites  was  quite  cured.    The  iodine,  when 
used  in  this  way,  is  not  intended  to  create  inflammatory  action  or 
adhesion,  but  to  stimulate  the  membrane  to  a  natural  healthy 
action.    No  doubt,  when  injected  under  such  circumstances,  it 
merely  brings  up  the  action  to  the  natural  standard ;  whereas,  had 
the  action  of  the  part  before  been  natural,  the  stimulus  would  have 
produced  inflammatory  action. 

Sometimes  support  and  pressure  will  assist  in  restoring  healthy 
action  of  the  membrane. 

Moni,ation  of  the  Ligaments.— This  is  found  existing  more  fre- 
quently in  young  persons  of  weak  or  scrofulous  habits ;  those  who 
hve  indoors  a  good  deal,  and  have  not  food  either  proper  in  quan- 
tity  or  in  quality.  It  is  also  seen  in  connection  with  synovial 
degeneration,  either  as  a  cause  or  an  effect.  It  is  one  of  the  pre- 
disposing causes  of  dislocation.  It  may  coexist  with  inflammation, 
or  with  thickening,  or  with  dropsy. 


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332 


PRINCIPLES    OF    SURGERY. 


Treatment— Attention  must  be  paid  to  the  general  health 
The  joint  must  have  rest,  and  support  in  the  form  of  a  bandage 
or  an  elastic  cap.  '  ° 

Cartilages  in  the  Joints.— These  foreign  bodies  are  so  called 
because  they  resemble  cartilage  in  appearance,  and  often  in  con 
sistence.     As  to  their  mode  of  formation,  different  explanations 
have  been  given ;  but,  as  is  often  the  case  under  such  circum 
stances,  there  is  no  single  way  by  which  they  are  produced     Thev 
frequently  seem  to  form  in  connection  with  the  synovial  mem 
brane;    sometimes   upon  the  free  surface,  sometimes  upon  the 
attached  surface,  and  sometimes  in  the  substance  of  the  mem 
brane.    At  first  there  will  be  a  mere  thickening  of  the  membrane 
which  in  time  will  take  the  form  of  a  distinct  tumor.     It  will  be 
remembered  that  sometimes,  as  a  result  of  inflammation,  there 
will  be  here  and  there  a  deposit  of  fibrinous  material,  which  may 
become  to  some  extent  organized.     This  is  more  frequently  seen 
where  the  membrane  folds  upon  itself,  forming  a  kind  of  border 
The  tumor  may  be  produced  in  this  way.     In  whatever  way  it  is 
originated,  there  is  at  first  a  thickening,  then  a  perceptible  eleva- 
tion, and  then  a  tumor,  which  has  a  comparatively  broad  base 
Gradually,  the  extent  of  attachment  is  diminished,  until  there  is 
the  smallest  pedicle.     Attached  in  this  way,  a  slight  force  will 
prove  sufficient  to  detach  it,  such  as  a  sudden  moving  of  the  joint. 
When  the  growth  commences  beneath  the  membrane,  the  body* 
when  it  becomes  detached,  will  present  a  very  smooth  surface' 
being  covered  with  synovial  membrane.  •       ' 

These  bodies  rarely  exceed  three  in  number,  and  often  there  are 
only  two— sometimes  only  one.  The  size  varies,  from  that  of  a 
small  pea  to  a  size  five  or  six  times  as  great.  In  form,  they  often 
approach  to  the  oval ;  but  there  is  no  particular  shape.  In  con- 
sistence, they  vary  from  fatty  tissue  to  bony.  They  are  sometimes 
of  a  yellowish  color,  sometimes  of  a  glistening  white.  They  may 
be  composed  of  natural  or  of  adventitious  tissue ;  fibrinous,  fibrous, 
cartilage,  cartilaginous,  fatty,  or  of  bone. 

The  joints  in  which  they  most  frequently  form  are  the  gingly- 
moidal— in  the  knee  especially.  They  may  remain  attached  by 
the  narrow  pedicle  for  some  time,  and,  after  they  are  separated, 
may  remain  in  the  joint  without  giving  any  indications  of  their 
existence.    Taking  the  knee-joint,— in  which  they  most  frequently 


CARTILAGES    IN    JOINTS. 


333 


are  found,-the  following  is  the  more  common  way  in  which  the 
disea  ,e  makes  itself  known.     The  person  is  walking,  and  takes, 
perhaps,  an  extraordinary  step-perhaps  suddenly  steps  to  a  lower 
•?u       ^v ''  ^°«*^'^t^neo"«ly  seized  with  excruciating  pain,  and 
with  inability  to  move  the  joint  in  either  way.     In  this  condition 
he  may  remain  for  some  minutes,  perhaps  a  much  longer  time, 
and  will  at  last  sink  to  the  ground  from  exhaustion.     All  at  once 
the  pain  may  cease,  and  no  further  trouble  be  experienced,  except 
a  considerable  soreness  in  the  joint.     The  explanation  is  simple. 
These  bodies  may  float  about  in  the  fluid  of  the  joint,  but  are 
mainly  ensconced  in  some  corner  of  the  synovial  cavity.      At 
times,  they  may  issue  therefrom ;  but  the  ends  of  the  articulating 
bones  press  them  back.     But  when  the  limb  is  made  to  take  an 
unusual  step,  one  of  these  little  bodies  will  sometimes  be  forced 
directly  between  the  articulating  surfaces,  so  as  to  cause  this  most 
sudden  and  severe  pain  in  the  sensitive  synovial  membrane ;  where- 
upon the  muscles,  sympathizing  with  the  injured  structure,  literally 
spring  into  action,  and  thereby  spasmodically  grasp  the  foreign 
body  between  the  ends  of  the  bones,  and  thus  the  pain  is  in- 
creased,  and  hence  there  continues  the  inability  to  move  the  joint 
At  last  the  muscles,  completely  tired  out,  may  relax,  and  the 
oreign  body  slips  away,  and  the  pain  ceases;  or,  the  individual, 
falling  down  exhausted,  or  fainting,  may  have  this  Body  dislodged  - 
from  Its  .unusual  position.     The  repeated  recurrence  of  such  at- 
tacks  Will  m  time  give  rise  to  inflammation  or  efi-usion,  and  may 
lead  to  disorganization  of  the  joint. 

Dzagnosis.^The  symptoms  above  described  are  characteristic 
of  this  affection,  and  are  therefore  reliable  diagnostic  marks.     On 
examination,  the  surgeon  may  at  times  feel  the  foreign  substance 
and  It  may  be  made  to  move  from  one  place  to  another  ' 

Prognosis.-Thk  must  be  cautiously  given.  There  is  danger  of 
the  serious  issue  above  referred  to.  There  is  also  danger  if  the 
body  is  allowed  to  remain,  and  danger  when  an  attempt  is  made  to 
remove  it. 

Treatment.-The  unfortunate  suff-erer  will  not,  as  a  general 
thing  seek  surgical  advice  until  he  has  had  two  or  more  attacks 
and  there  may  be,  as  a  result  of  those  attacks,  more  or  less  local 
inflammation.     Should  there  be  any  such  evil  resulting  from  the 
attack,  It  must  be  in  the  first  place  attended  to. 


li    I 


if  I 


M^  i 


■t" 


334 


PRINCIPLES    OF    SURGERY. 


The  surgeon  may  adopt  a  course  of  palliative  or  preventive 
treatment,  or  he  may  aim  to  effect  a  radical  cure  by  a  removal  of 
the  body  from  the  joint. 

If  by  any  appliance  the  body  can  be  so  controlled  that  it  may 
not  be  caught  between  the  articulating  bones,  the  surgeon  may  be 
satisfied,  while  the  patient  will  be  fully  contented.    To  accomplish 
this,  pressure  is  frequently  applied  to  the  joint  by  a  bandage 
which,  to  allow  of  motion  in  the  joint,  will  have  to  be  elastic' 
Knee-caps  are  manufactured  for  this  purpose.    It  must  not  be  too 
tight,  else  it  will  affect  venous  flow  in  the  limb;  yet  it  should  fit 
closely.     When  the  limb  is  flexed,  the  bandage  is  put  upon  the 
stretch,  by  which  means  a  greater  degree  of  support  is  obtained 
at  the  very  time  it  is  most  required ;  and  thus  the  foreign  body  is 
prevented  from  straying  out  of  its  usual  place  of  abode.    But 
not  unfrequently  this  palliative  treatment  will  fail,  and  the  recur- 
ring painful  attacks  will  produce  most  distressing  results,  and  will 
tend  to  inflammation  and  disorganization.     The  patient  will  pro- 
bably  become  solicitous  of  more  effectual  relief— of  securin..  the 
removal  of  the  foreign  body  from  the  joint.     Heretofore,  and  by 
many  even  now,  it  was  deemed  a  dangerous  operation  to  make  an 
incision  into  a  joint.     It  has  consequently  been  recommended  to 
make  an  indirect  opening,  so  that  none  of  the  synovial  fluid  may 
escape.     The  operation,  as  usually  practised,  consists  at  first  in 
making  an  indirect  incision  with  a  small  tenotomy  knife.    Before 
commencing,  the  position  of  the  body  to  be  removed  must  be  defi- 
nitely ascertained.    Should  it  not  lie  in  the  place  most  convenient 
to  be  reached,  efforts  must  be  made,  by  careful  manipulation,  to 
get  It  m  such  position.    When  in  the  knee,  the  preferable  place  is 
on  the  inner  side,  at  the  extremity  of  the  synovial  pouch.    An 
assistant  should  fix  the  body  during  the  operation;  or  a  fine 
needle  may  be  made  to  transfix  it.    The  knife  having  been  passed 
m  an  oblique  direction  to  the  body,  the  synovial  membrane  is  di- 
vided to  a  sufficient  extent  to  allow  an  easy  exit  of  the  substance, 
which  will  then  be  made  to  pass  through  this  aperture,  by  gentle, 
well-directed  pressure.     The  knife  being  withdrawn,  the  finger 
will  follow  its  track,  so  as  to  close  it,  that  little  or  no  synovial 
fluid  may  escape.     The  body  will  then  be  forced  out  of  the  joint, 
and  made  to  occupy  a  place  in  the  cellular  tissue  for  some  days,' 
until  the  wound  in  the  synovial  membrane  is  quite  healed.    The 


WOUNDS    OP    JOINTS. 


335 


operatron  will  then  be  completed  by  making  a  direct  incision  upon 
the  body,  and  removmg  it.  This  is  the  operation  more  frequently 
chosen  by  the  surgeon ;  but  sometimes  the  body  is  removed  at  one 
operation.  The  former  is  deemed  the  most  safe,  inasmuch  as  but 
ittle  synovial  fluid  can  escape.  But  even  should  that  fluid  escape 
0  some  extent,  it  will  not  be  attended  with  much,  if  any,  danger 
( r...  Wounds  of  Joints.)  While,  on  the  other'hand,':  foreign 
body  IS  forced  into  the  cellular  tissue,  where  it  cannot  but  be  provo- 
cative of  great  irritation.  ^ 

The  after-treatment,  in  both  cases,  is  absolute  rest  of  the  joint 
and  diligent  application  of  cold  water. 

Wounds  of  Joints  have,  until  very  recently,  been  regarded  as 

tZ7  TI  "'''  *'  *'^  "*^^"^^  ''  '  J^^*-     The'escape  of 
the  fluid  and  the  entrance  of  air,  it  was  thought,  would  necessarily 

produce  a  degree  of  inflammation  that  would  certainly  impair  or 
destroy  the  joint.     That  such  terminations  have  frequently  fol- 
lowed wounds  of  the  joint  is  undoubtedly  true;  but  that  sui  dis- 
astrous results  must  follow  as  a  consequence,  there  is  abundant 
reason  to  doubt.     The  instrument  which  penetrates  to  the  joint  i 
often  small  and  sharp.     The  pain  arising  therefrom  is  very  slight, 
and  herein  hes  the  danger.     The  patient,  suff-ering  no  pain  no^ 
mconvenience,  and  unaware  of  the  danger,  gives  little  or  no  heed 
to  It,  very  likely  continuing  to  use  it.     Through  the  wound  the 
synovial  fluid  has  drained  off,  and  continues  to  flow,  so  that  the  joint 
IS  not  supplied  with  the  necessary  lubricating  fluid.     The  friction 
arising  from  motion  soon  induces  irritation,  which  continuing,  will 
terminate  m  inflammation.     The  inflammation,  therefore,  Is  not 
the  necessary  consequence  of  the  wound ;  but  instead  is  th^  result 
of  motion  m  the  joint  while  the  parts  are  unsupplied  with  fluid  to 
prevent  friction.     The  view  that  the  entrance  of  air  into  the  open 
jomt  IS  a  cause  of  irritation,  cannot  be  received.     Indeed    it  is 
impossible  to  conceive  by  what  natural  law  air  could  be  forced  into 

jomt  although  open      Atmospheric  pressure  is  quite  as  gre 
upon  the  tissue  around,  as  upon  the  orifice  of  the  wound      We 
cannot  understand  any  other  effect  arising  from  the  absence'of  the 
fluid  than  a  closer  contact  of  the  opposite  structures  of  the  joint. 

of  f  rr;;^ ;  T'''  '^'"^^'^^*  °^  ^  --^  -^o  theiviy 

of  a  joint  IS  the  discharge  of  the  synovial  fluid.     The  degree  of 
^m,  as  well  as  other  symptoms,  will  depend  upon  the  chLcte 


!  '    I 


i^M 


i  I 

'  f 


If 


'iii 


I  ■ 


,  '^  Hi, 
1   '11. 


( 

■ 

1 
1- 

1 

1 

1 

1 

i 

111. 

i 

336 


PRINCIPLES    OF    SURGERY. 


of  the  wound,  and  the  subsequent  irritation  from  attempts  to  use 
the  joint. 

Treatment. —The  essential  steps  to  be  taken  in  the  treatment 
will  be  inferred  from  the  remarks  made  relative  to  the  real  source 
of  danger— the  cause  of  the  inflammation.  Absolute  repose  of  the 
joint,  with  the  ordinary  treatment  of  wounds,  is  all  that  is  re- 
quired. 

The  process  of  healing  will  commence  and  proceed  in  this  case 
as  in  any  other  wound.  Although  the  synovia  may  have  escaped' 
yet  in  due  time  there  will  be  a  new  supply  secreted  by  the  mem- 
brane. When,  however,  from  the  extent  of  the  injury,  or  from 
injudicious  treatment,  inflammation  has  supervened,  the  treatment 
heretofore  detailed  will  be  pursued. 

Deformities  at  the  Joint. — These  may  result  from  diseases  as 
ulceration  or  softening  of  tissue,  from  irregular  action  of  the 
muscles,  from  violent  displacement  or  dislocation. 

When  deformity  results  from  chronic  disease  of  a  joint,  little  or 
nothing  can  be  done  to  remedy  or  remove  it.  In  the  progress  of 
such  diseases,  when  it  becomes  evident  to  the  surgeon  that  partial 
or  complete  anchylosis  will  result,  he  should  place  the  limb  in  that 
position  as  to  flexion  or  extension  which  will,  to  the  patient,  be 
the  most  useful,  or,  perhaps,  the  least  unsightly.  The  position  in 
society  of  the  patient  and  his  own  wishes  must  be  fully  considered. 
Nature  will  often,  in  the  course  of  time,  remove  the  obstacles  to 
motion.  In  all  of  these  cases,  irregular  contraction  of  muscles,  by 
which  the  bones  may  be  drawn  into  unnatural  relationship,  should 
be  counteracted,  and,  if  necessary,  the  unruly  muscle  divided  at 
its  tendon.  An  apparatus  should  be  specially  prepared,  by  which 
the  limb  will  be  supported,  and  at  the  same  time  the  muscles  effec- 
tually resisted. 

Deformities,  resulting  from  a  want  of  uniform  or  harmonious 
action  around  the  joint,  may  be  due  to  congenital  defects,  or  from 
those  which  have  been  acquired,  and  which  depend  upon  some  dis- 
ease of  the  cerebro-spinal  system. 

Varieties. — Congenital  deformities  are  of  two  kinds.  1.  Those 
which  proceed  from  arrest  or  excess  of  development,  from  spinal 
irritation,  &c.  2.  Those  which  are  caused  by  simple  malposition 
in  utero.     The  former  may  be  hereditary ;  the  latter  rarely  so. 


DEFORMITIES    OF    JOINTS. 


887 


The  cause  of  these  congenital  deformities  is,  in  many  cases 
Z7  pressure.     Oftentimes  .hey  will  be  ;ttrib„ted^^ma: 

holds  tST'""''    M  V'  ""=  ""'■'"»"'  "'^^'f"  "h"  principally 
holds  tlus  op.mon.    Mother's  marks  and  deformities  will  now  and 

t::tZ2    :r'T'  J-?  ="'""  «'  ™™-  ki„dshavenow 
the  woma!  r  '  "'•  ■"'P'"*»«<>--    !■>  the  experience  of 

the  woman  dunng  „,ne  months  of  pregnancy,  almost  every  con- 

alltion  cT     ;,  ^"'"  ™™'^  °'  circumstances,  and  the  im- 

sTe  one  of  th         '  """""  "'*  *'  "^""»''  "P»  ">^  "Wld 
some  one  of  the  many  occurrences  during  her  time,  especially 

«hen  under  the  morbid  stimulus  of  superstition.  ''        '^ 

Ihe  more  frequent  cause  is  a  departure  from  natural  develon- 
ment,  the  cause  of  which  may  lie  hidden.  It  may  hav  a  m  tt 
nal  source,  or..t  may  be  some  circumstance  aside  frL  the  m^th  . 
The  arrest  of  development  may  be  in  certain  muscles,  or  it  may 
be  ,n  the  cerebro-spinal  centres,  which,  in  consequence  fair  to 
govern  certain  muscles.  sequence,  tail  to 

ant!ton"r.  h,f  T'"""  "'  "  '""'  ''™'  '»  "  «-'™  -'-'. 
an  agonist  c,  but  when  m  a  state  of  health,  the  balance  of  power 

r  onrslfof  mu::i    ?  T  '"  ''^*"'  '■"■"°"^-    ^'^  °-  ■»- 
or  one  set  of  muscles  fails  to  act,  either  on  account  of  its  own 

nabih  y,  or  because  the  necessary  nervous  stimulus  is  w  tlherd    ' 
then  the  antagonistic  muscle  or  muscles  have  the  power  to  rlt 

he  limb  and  deformity  will  ensue,  as  in  club-foot.     It  is  pi  b t 
that  undue  action  of  a  muscle  may  be  the  cause  of  the  defrmTv 
but^^speaking  generally,  it  is  a  want  of  power  in  thelS 

This  pathological  state  of  the  muscles  may  exist  at  the  time  of 
XtnTl  "  "  -y  afterwards  gradually  come  on  ac! 
binh    wV T^  "■'  °°'''*'"  ™'»'='i"e  causes,  acting  after 

traction  ot  the  muscles,  as  in  convulsions  f       f     ^ 

effo":*  '"''''''  ■'""°"  ""^"^  --'0  ^y  a  strong 

Whatever  the  cause  of  the  deformity,  when  existing  fov  o  f 
atructura.  changes  will  inevitably  take%iar  ::Z^£^  ^ 

22 


.     t 

11 

Ll    iij. 

S38 


PRINCIPLES    OF    SURGERY. 


posing  the  joint,  thereby  complicating  the  case,   and  rendering 
recovery  almost  or  altogether  unlikely. 

Treatment.— When  the  deformity  is  due  simply  to  malposition 
in  utero,  it  may  be  righted  by  the  unaided  powers  of  nature. 

When  the  deformity  is  due  to  irregular  action  of  the  muscles 
one  muscle  being  more  or  less  feeble,  the  more  early  the  treatment 
is  commenced,  the  more  likely  is  it  to  be  successful. 

The  indications  are,  to  overcome  the  power  of  such  muscles  as 
produce  the  deformity.  The  surgeon  cannot  stimulate  the  para- 
lyzed or  weakened  muscles  to  their  natural  power;  so  he  must  re- 
duce the  power  of  those  which  are  opposed  to  them.  There  are 
two  ways  in  which  this  can  be  done:  1st,  by  division  of  tendons; 
2d,  by  mechanical  extension,  or  by  both  of  these  means. 

Division  is  to  be  eifected,  when  practicable,  by  a  subcutaneous 
incision  (tenotomy).  For  this  operation  a  small  tenotomy  knife  is 
to  be  used.  This  operation  is  of  a  comparatively  recent  date,  but 
is  one  which  can  be  safely  and  easily  performed,  and  which  will, 
in  a  vast  majority  of  cases,  afford  the  greatest  relief  to  the  patient; 
■  for  there  is  nothing  more  distressing  to  a  person  than  deformity. 
When  a  tendon  is  divided  the  ends  will  be  drawn  widely  apart  by 
the  contraction, of  the  muscle.  The  hiatus  thus  made  will,  in  time, 
be  occupied  by  an  adventitious  material,  unlike  the  normnl  tendon, 
but  inoorporatcd  with  it,  and  being  equally  useful. 

But  sometimes  this  operation  is  unnecessary,  or  is,  perhaps,  ob- 
jected to  by  the  friends ;  in  which  case  protracted  extension  may 
be  resorted  to.  By  this  means  the  over-powerful  muscle  is  over- 
come, the  bones  of  the  joint  are  placed  in  proper  relationship,  and, 
after  a  time,  the  muscles  which  had  been  unable  to  cope  with  those 
opposed  to  them,  regain  or  attain  the  strength  which  is  natural. 
Thereafter  the  action  of  all  the  muscles  will  be  harmonious.  When 
taken  at  an  early  age,  mechanical  extension  will  often  prove  ade- 
quate to  effect  a  cure.  "The  removal  of  a  deformity,  in  general, 
requires  the  application  of  great  power,  steadily  and  unremittingly 
maintained.  But  the  force  employed  must  be  so  gradual,  so  gen- 
tle, so  well  adjusted,  that  it  neither  pains  the  patient,  nor  rubs  the 
ykin.  If  the  pressure  be  too  great,  the  patient  will  soon  find  the 
pain  unendurable,  when  the  surgeon  will  be  obliged  to  relax  it,  and 
so  he  may  go  on  for  weeks,  and  even  months,  alternately  over- 
pressing  and  relaxing,  but  making  no  steady  progress  towards 


DEFORMITIES    OF    JOINTS. 


889 


S^^^S 


cure.  For  however  ineffectual  violent  extension  may  be  against  a 
firm  contraction  there  are  few,  perhaps  no  tissues,  which  can  resist 
the  application  of  constant  and  steady,  yet  gentle-acting  force." 
(Holmes  Coote.)  It  follows  that  for  some  time  after  the  treat- 
ment has  commenced,  there  will  be  no  perceptible  advantage 
gained.     It  is  a  matter  of  months,  not  of  days 

Mechanical  aid  will  often  have  to  be  employed  conjointly' with 
tenotomy.  Indeed,  in  several  forms  of  club-foot,  this  is  absolutely 
necessary.  •' 

In  every  case  where  the  deformity  has  existed  so  long  that 
structural  change  has  taken  place  in  the  bone,  the  process  of  cure 
wil  be  protracted,  and  the  result  less  certain.  At  least,  so  pei- 
tect  a  joint  cannot  be  hoped  for. 

"  The  occasional  non-union  of  tendons  induces  me  to  mention  to 
you  two  rules  which  should  be  always  observed.  First,  never  di- 
vide a  tendon  whether  in  hand  or  foot,  in  the  dense  portion  of  the 
synovial  sheath  ;  the  retracted  ends  become  adherent  to  the  sheath; 
there  is  no  re-establishment  of  the  continuity  of  the  tendon,  and 
there  is  a  corresponding  loss  of  motion.  In  the  second  place,  do 
not  extend  the  parts  too  rapidly  after  operation,  for  the  fear  of 
non-union  is  not  wholly  imaginary,  even  when  the  operation  is 
performed  in  the  proper  place  and  manner."     (Holmes  Coote.) 

It  IS  necessary  to  allude  to  another  species  of  deformity,  rcsult- 
mg  from  Weakness,  which  may  be  either  congenital  or  acquired. 
It  18  not  in  the  muscles  whore  the  weakness  exists,  but  in  the  bones 
and  hgaments ;  instances  of  which  are  seen  in  the  knock-knee,  the 
bow  leg,  and  i>i  the  flat  foot.  They  are  incapable  of  sustaining 
the  supenncumbent  weight,  and  gradually  yield  under  it,  untH 
very  considerable  deformity  exists,  and  locomotion  is  atJen.led 
with  great  awkwardness,  or  indeed,  it  may  become  almost  impos- 

These  affections  are  more  commonly  the  result  of  constitutional 
weakness,  yet  there  may,  in  addition,  have  been  some  local  cause. 

2reatment.~Attent\on  must  be  paid  to  the  constitution.  It  is 
an  affection  often  seen  in  the  children  of  large  towns  and  cities, 
who  have  neither  good  food  nor  pure  air.  In  those  cases,  to  nnp. 
ply  those  requisites  to  health  may  be  sufficient  to  turn  aside  tlio 
course  of  d.sease.     Tonics  will,  as  a  general  thing,  be  demandcvl. 

With  respect  to  the  local  treatment,  if  onu.i.i.  ;,,  -^V-     - 


340 


PRINCIPLES    OP    SURGERY. 


port,  and  when  there  is  actual  deformity,  such  pressure,  direct 
and  indirect,  as  will  gradually  restore  the  parts  to  their  natural 
position.  In  the  young,  and  when  the  deformity  is  slight,  a  lim- 
ited time  will  be  sufficient  to  effect  a  cure,  but  in  the  more  aged, 
and  when  the  deformity  is  considerable,  a  protracted  period  will 
be  necessary.  The  time  will  vary  from  a  few  weeks  to,  perhaps 
two  years. 


CHAPTER   XLII. 

Dislocations :  Causes  -  Clnssification  -  Diagnosis-  Prognosis  -  Patholoffv- 
Treatment-Indications-Keduce  the  Principal  One-Remove  Obstacles- 
Complications. 

Dislocation  of  Bone.—Hy  dislocation  of  bone  is  understood  a 
displacement  at  the  site  of  articulation  of  two  or  more  bones     It 
is  ordinarily  due  to  violence.     When  it  is  remembered  that  to 
allow  that  play  of  the  limb  for  which  joints  exist,  there  must  be 
a  degree  of  looseness,  so  to  speak,  in  the  joint,  that  the  ligaments 
must  be  of  sufficient  length  to  permit  of  the  necessary  motion;  and 
still  more,  when  we  consider  the  diversified  action  of  the  muscles 
by  which  motion  in  a  joint  is  effected,  there  can  Lo  no  difficulty 
at  the  same  time,  in  understanding,  that  a  predisposition  to  dislo! 
cation  IS  a  necessary  consequence  of  the  motion,  and  the  means 
by  which  it  is  made. 

Camcs  of  dislocation  may  be  divJded  into  predisposinq  and  im- 
mediate. 

Predisposing  Causes.--T\xQ  period  of  middle  life  in  man,  when 
he  IS  ordinarily  exposed  to  accidents,  may  be  designated  a  predis- 
posing cause  of  dislocation.  At  tliis  period  the  bones  possess  the 
greatest  degree  of  firmness.  They  will  not  easily  bend,  as  in  the 
young,  nor  break,  as  in  the  aged.  So  when  force  is  violently  used 
against  a  Imib,  the  joint  being  the  weaker  point,  is  the  most  likely 
to  yield.  A  second  predisposing  cause  of  dislocation  is  a  prdcr- 
naturally  lax  condition  of  the  ligaments;  also  an  unusual  length, 
1  heso  may  be  a  congenital  defect,  or  they  may  be  tlie  result  of 
disease.     Again,  some  joints,  because  of  their  peculiar  form,  arc 


DISLOCATIONS. 


841 


more  liab  e  than  other  joints,  to  dislocation.     The  shoulder-ioint 
particu  arly,  is  subject  to  displacement.    Here  is  a  ball  and  socket 
joint  at  ^hich  IS  very  extensive  motion.     The  socket  is  necessa- 
rily shallow,  while  the  articulating  surface  of  the  head  of  the  hu- 
merus  is  very  extensive.     The  sweep  of  the  arm  in  its  varied  and 
extensive  movements,  demands  the  above  condition.     To   allow 
this  diversified  motion  the  ligaments  must  be  sufficiently  free,  and 
this  freedom  of  motion  must  carry  with  it  a  corresponding  degree 
of  weakness.    Hence  it  is,  that  the  shoulder-joint  is  a  frequent  seat 
of  dislocation.     Again,  take  the  radius  where  its  superior  extre- 
mity articulates  with  the  humerus  and  ulna.     It  is  by  this  articu- 
lation   principally,  that  the  complicated  motion  of  the  hand  is 
allowed,  and  for  this  motion  there  must  be  a  freeness  at  the  site 
of  articulation.     The  consequence  is,  the  head  of  the  radius  can- 
not resist  any  great  force  when  it  is  applied  in  such  a  way  as  to 
try  the  strength  of  its  ligaments.     A  joint  may  be  predisposed  to 
displacement  in  consequence  of  some  congenital  defect  in  the  bones 
thereof.     Paralym  of  one  or  more  muscles  around  a  joint  will 
predispose  to  the  accident,  for  the  bones  are  held  together,  not 
alone  by  ligaments,  but  as  well  by  the  muscles.     Another  predis- 
posing cause  is  diseme,  ivheniby  the  tissues  are  ulcerated.     It  may 
be  the  ligaments,  or  the  cartilage,  or  the  bone.     Still  another  pre- 
disposing  cause,  is  the  presence  of  tumors  or  morbid  deposits,  which 
gradually  affect  the  integrity  of  the  joint. 

Immediate  Causes.-Thcve  are  two,  external  violence  and  mus- 
cular  action.  The  violence  may  be  direct  or  indirect.  For  in- 
stance,  the  head  of  the  radius  may  be  dislocated  by  a  fall  upon 
the  part  or  upon  the  hand.  Again,  the  shoulder  may  be  put  out 
of  joint  by  a  force  directly  applied  to  the  part,  or  by  its  applica- 
tion to  the  elbow  or  hand. 

Dislocation  from  muscular  action  is  not  of  common  occurrence 
yet  It  docs  sometimes  occur.     In  convulsions,  or  in  any  case  where 
there  is  a  want  of  harmonious  action,  if  the  more  powerful  muscles 
act  suddenly,  displacement  may  be  produced. 

The  two  causes  may  act  conjointly,  in  the  following  manner- 
by  some  external  violence,  the  humen.H,  at  the  shoulder,  we  will 
supposes  to  a  slight  extent  displaced,  by  external  force.  Imme- 
diately thereupon,  the  muscles  connected  with  that  joint  are  sti- 
Ululated  to  contraction ;  but  owing  to  the  di«pl.-nmont,  althou-h 


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342 


PRINCIPLES    OF    SURGERY. 


slight,  the  harmony  of  action  in  the  muscles  is  destroyed ;  some 
perhaps,  are  acting  at  a  disadvantage.  The  result  is  that  the 
bone,  slightly  displaced,  is  caught  by  muscles  whose  power,  under 
the  circumstances,  is  adequate  to  complete  the  dislocation.  It  is 
by  a  similar  process  that  a  primitive  dislocation  is  converted  into 
a  consecutive  dislocation. 

Olaasification,— The  following  are  the  several  classifications 
given  by  different  writers:  Primitive,  and  consecutive;  incom- 
plete, or  subluxation,  and  complete;  recent,  and  old;  simple,  com- 
pound, and  complicated. 

Allusion  has  been  made  above  to  the  process  whereby  a  primitive 
dislocation  is  changed  to  a  consecutive.  To  illustrate,  take  one  of 
considerable  interest,  occurring  in  the  hip.  The  most  frequent 
form  of  dislocation  at  that  joint  is  upon  the  dorsum  of  the  ilium. 
Now,  it  sometimes  happens  that,  by  muscular  action,  or  a  secon- 
dary external  force,  the  head  of  the  femur  is  carried  from  the 
dorsum  into  the  ischiatic  notch.  Indeed,  when  we  look  at  the 
anatomy  of  the  parts,  it  is  not  easy  to  conceive  how  direct  dislo- 
cation into  the  ischiatic  notch  can  take  place ;  and  the  conclusion 
is  almost  forced  upon  us,  that  this  form  of  dislocation  is  always 
consecutive. 

The  terms  "incomplete"  and  "complete"  are  sufficiently  plain. 
It  will  not  unfrequently  happen  that  the  displacing  force  will  not 
be  sufficient  to  entirely  separate  the  articulating  surfaces. 

Simple,  compound,  and  complicated,  have  exactly  the  same  sig- 
nification as  when  used  in  connection  with  fractures.  (To  which 
the  student  may  turn.) 

Symptoms  of  Dislocation. — Like  those  of  fracture,  they  may  be 
divided  into  such  as  are  characteristic  of  dislocation,  and  such  as 
may  exist  from  otlier  causes  as  well.  Of  the  latter,  there  are 
pain,  numbness,  paralysis,  loss  of  motion,  and  constitutional  dis- 
turbance. Of  the  former,  wiiich  are  physical  signs,  there  are, 
first,  change  in  the  entire  form  of  the  limb.  It  is  at  once  plain, 
witiiout  demonstration,  that  displacement  cannot  exist  at  a  joint 
without  its  being  palpable  to  any  beholder.  One  species  of  de- 
formity requires  Hpecial  notice :  that  is,  a  change  in  the  length  of 
the  limb  ;  it  may  ho  shortened,  or  it  may  be  lengthened.  Another 
symptom,  and  one  of  importance,  is  the  unnatural  rigidity  of  the 
limb  at  the  dislocated  joint.    Neither  the  patient  nor  the  surgeon 


DISLOCATIONS. 


843 


can,  to  any  extent,  move  the  joint.  Again,  around  every  joint, 
in  Its  natural  state,  are  bony  prominences.  When  displacement 
has  taken  place,  there  will  be  an  absence  of  the  usual  prominent 
points,  and,  instead,  unnatural  eminences. 

Diagnosis.— The  affections  with  which  dislocation  may  be  con- 
founded  are  fractures,  bent  bones,  and  sprains. 

The  educated  surgeon  will  experience  no  difficulty  to  distinguish 
between  a  fracture  and  a  luxation ;  for  while  the  two  affections 
have  some  symptoms  in  common,  yet  there  are  enough  peculiar  to 
each  to  constitute  reliable  diagnostic  marks.     It  is  only  when  a 
fracture  is  near  the  joint  that  a  mistake  can  possibly  be  made. 
The  most  prominent  symptom,  of  both  dislocation  and  fracture   is 
deformity.     Now,  when  the  deformity  is  due  to  fracture,  the  sur- 
geon can  readily  restore  the  parts  to  their  natural  form ;  whereas, 
in  dislocation,  the  ends  of  the  displaced  bones  are  fast  locked  in 
their  abnormal  condition,  unless  the  ligaments  have  been  torn  (in 
which  case  there  is  likely  to  be  a  compound  dislocation).     Conse- 
quently, reduction  to  the  normal  position  is  difficult.     Moreover, 
although  a  fracture  is  easily  reduced,  it  will,  with  a  corresponding 
easiness,  relapse  into  deformity  when  unsupported ;  while,  on  the 
contrary,  a  dislocation,  when  reduced,  will  almost  always'  remain 
so.     In  other  words,  in  a  fracture,  there  is  a  condition  analogous 
to  a  second  Joint;  while  in  dislocation,  the  motion  of  the  natural 
joint  is  absent.      The  absence  of  crepitus  is  a  negative  symptom 
of  some  value.     ( Vide  Symptoms  of  Fracture^) 

Prognosis  and  Pathologg. —Thk  will  bo  modified  by  a  variety 
of  circumstances.  Dislocations  of  all  joints  are  not  equally  se- 
rious, nor  arc  the  several  dislocations  of  the  same  joint  ciiually 
dangerous  in  their  issue.  Speaking  generally,  all  dislocations, 
when  taken  in  time,  are  reducible ;  and  unless  some  serious  com- 
plication  attend,  there  need  be  no  fear  as  to  the  result.  But  if  a 
dislocation  has  existed  for  some  time,  grave  obstacles  may  have 
arisen,  which  cannot  be  overcome. 

When  a  joint  remains  some  time  displaced,  there  will  be  an 
effort  on  the  part  of  nature  to  accommodate  herself  to  the  abnor- 
mal condition.  Bonds  of  adhesion  may  form,  whereby  the  bones 
are  securely  bound;  or  a  new  resting-place  may,  in  part,  have 
formed  for  the  head  of  the  bone.  The  direction  of  the  displace- 
ment,  and  the  degree,  will  bo  considered  in  forming  a  prognosis. 


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344 


PRINCIPLES    OF    SURGERY. 


And  again,  the  amount  of  injury  to  the  soft  parts,  or  any  special 
complication,  will  weigh  in  coming  to  a  decision. 

When  a  dislocation  continues  unreduced,  important  changes  will 
take  place,  and,  in  time,  from  absorption  and  new  formation  a 
degree  of  motion  will  be  obtained.  ' 

Treatment- The  Indications.-In  the  first  place,  the  general 
condition  of  the  patient  must  be  attended  to;  in  the  second  place 
reduce  the  dislocation;  and  in  the  third  place,  prevent  inflamma. 
tzon      The  principal  thing  in  the  treatment  is  to  effect  reduction 

Should  the  surgeon  be  near  at  hand  at  the  time  the  accident 
occurs,  he  may  with  little  difficulty  restore  the  bones,  and  with 
comparatively  little  pain  to  the  patient,  for  the  parts  will  yet  be 
.ax.     But  after  a  little  time  has  elapsed,  the  muscles  will  become 
contracted,  and  the  sensitiveness  of  the  part  acute.    The  patient's 
fears  ought,  as  much  as  possible,  to  be  calmed;  and  should  the 
suffermg  and  difficulty  promise  to  be  great,  chloroform  must  be 
admm.stered.     This  may  be-necessary  even  before  examination  is 
n-ade      Should  inflammation  have  arisen,  it  is  not  necessary  or 
desirable  to  wait  for  it  to  subside ;  indeed,  perhaps  the  reduction 
IS  necessary,  that  the  inflammation  may  be  arrested.    When  how 
ever,  the  inflammation  is  due  to  great  violence,  or  previous  ill- 
judged  attempts  to  reduce  the  parts,  then  it  may  be  well  to  wait  a 
tew  days,  that  the  irritation  may  subside. 

Obstacles  to  Reduction.— To  accomplish  reduction,  the  surgeon 
must  understand  fjilly  the  obstacle  or  obstacles  to  be  overcome 
There  can  be  no  greater  piece  of  barbarity  than  to  attempt  to  ef- 
fect reduction  by  brute  force,  without  a  knowledge  of  the  anatomy 
and  the  function  of  the  muscles.  The  obstacles  which  may  exist 
are :  1.  Muscular  action.  2.  Form  of  the  part,-locking  of  the 
bones,  or  held  by  firm  ligaments.  3.  Morbid  adhesions.  4  Inter- 
positron  of  tendons  or  ligaments.  The  muscular  contraction,  and 
the  unyielding  nature  of  the  ligaments,  constitute  the  most  formi- 
dable obstacles. 

To  overcome  muscular  contraction,  various  measures  may  be 
resorted  to.  The  cause  of  the  more  powerful  action  of  the  mus- 
cles IS  the  unusual  relationship  in  which  the  articulating  ends  are 
placed.  Some  muscles  are  thereby  put  upon  the  stretch,  while 
others  are  rendered  inactive  from  their  points  of  attachment  being 
approximated. 


DISLOCATIONS. 


345 


The  first  principle  of  treatment  which  has  been  generally 
taught  IS  to  overcome  the  muscular  action  by  mechanical  means  • 
literally,  to  enter  into  a  contest  with  the  muscles,  and  to  endeavor 
to  overcome  them  by  sheer  force,  tiring  them  out.  But  the  sur- 
geon should  not  resort  to  such  harsh  procedure  until  he  has  duly 
considered  whether  other  and  gentler  means  may  not  be  employed 
to  accomplish  the  same  end.  At  such  times,  the  muscles  are  ex- 
ceedingly sensitive,  and  are  quick  to  protect  the  joint  at  the  least 
irritation,  especially  when  the  patient  is  laboring  under  mental 
excitement  and  fear.  Hence  the  importance  of  quieting  the  mind 
and  diverting  the  attention. 

Now,  it  is  possible,  in  some  forms  of  dislocation,  to  so  manipu- 
late the  hmb  that  the  muscles  will  not  be  to  any  extent  irritated 
and  at  the  same  time  the  displaced  ends  will  be  gradually  brought 
toward  their  natural  position.     Sometimes,  by  dexterous  move- 
ments,  the  dislocation  may  be  reduced,  and  the  patient  be  unaware 
0    Its  completion ;  at  other  times,  the  ends  having  been  brought 
almost  together,  the  surgeon  can,  by  a  quick  motion,  cause  them  to 
slip  into  their  natural  relationship.    That  this  may  prove  successful, 
they  must  be  so  brought  into  position  that  the  muscles  around  the 
joint  will,  when  they  start  to  act,  contract  harmoniously;   and 
then    by  their  united  action,  the  reduction  is  completed.      But 
should  the  effort  be  made  before  the  bones  are  thus  placed,  the  only 
effect  will  be  to  aggravate  and  increase  the  degree  of  displacement. 
It  IS  upon  these  principles  that  dislocation  of  the  femur  upon  the 
dorsum  of  the  ilium  is  now  often  treated  successfully.     It  per- 
haps more  frequently  happens  that  this  milder  and  more  scientific 
mode  IS  unavailing,  and  it  becomes  necessary  to  use  mechanical 
force  to  overcome  the  action  of  the  muscles,  or  adopt  some  con- 
stitutional treatment  to  produce  relaxation.     To  carry  out  the 
former,  the  surgeon  will  apply  extension  and  counter-extension. 
This  may  be  done  by  fixing  the  body  with  one  hand,  and  with  the 
other  using  extension  to  the  extremity  of  the  limb.     In  this  an 
assistant  may  take  part.     Extension  may  be  made  by  a  clce^ 
hitched  bandage.    Upon  this,  extension  can  be  made  by  assistants 
or  by  pulleys.     In  whatever  way  the  extension  is  made,  whether 
by  hand  or  by  pulleys,  it  must  be  done  very  steadily.     It  will  not 
do  to  apply  great  force  at  once ;  rather,  the  force  must  be  gentle, 
Uniterm,  and  continued,  until  the  muscles  are  literally  tired  out 


.if:"' 


346 


PRINCIPLES    OP    SURGERY. 


whereupon  the  bones  may  at  once  glide  into  place.  The  extension 
must  be  made  from  the  bone  dislocated ;  for  instance,  if  at  the 
hip-joint,  the  hitch  must  be  applied  to  the  lower  end  of  the  femur 
and  not  from  the  leg  below  the  knee.  It  has  been  objected  that 
the  application  of  the  bandage  to  the  same  bone  causes  the  mus- 
cles to  contract  the  more  forcibly.  This,  to  some  extent,  is  (true  • 
yet  they  will  be  the  sooner  exhausted,  while  the  advantage  gained 
by  the  more  immediate  power  of  extension  is  of  considerable  im- 
portance. 

The  direction  in  which  the  extension  is  made  will  be  such  as 
will  cause  the  head  of  the  displaced  hone  to  traverse  in  an  opposite 
direction  the  course  which  it  took  at  the  time  dislocation  was  effected 
The  counter  extension  consists  in  fixing  the  body  so  that  the  ex- 
tension will  be  the  more  availing. 

Constitutional  Eemedies. —Yarions  constitutional  means  mav  be 
employed  to  cause  relaxation  of  the  muscles.  The  most  important 
is  chloroform,  and  it  ought  always  to  be  administered  when  the 
difficulty  is  great.  But  when  reduction  is  sought  by  manipula- 
tion, anaesthetic  agents  should  not  be  given,  for,  as  we  have  seen, 
the  muscles  act,  at  the  last  moment,  an  important  part  in  com- 
pleting the  reduction.  Formerly  bloodletting  was  deemed  neces- 
sary, but  in  this  our  day,  no  excuse  can  be  offered  for  a  wasteful 
expenditure  of  the  patient's  strength  and  health.  The  hot  bath 
tart,  emetic,  tobacco,  intoxication,  &c.,  have  been  used  to  advan- 
tage, but  chloroform  takes  the  place  of  all  these. 

The  next  obstacle  to  reduction  which  we  have  to  consider,  is  the 
locking  of  the  bones.     At  the  time  dislocation  is  accomplished  the 
ligaments  are  very  much  stretched,  and  if  not  torn,  they  will  soon 
recover  their  natural  state,  and  so  will  as  firmly  bind  the  bones  in 
their  abnormal  position  as  th.y  bound  them  in  their  natural  state. 
The  heads  of  the  bones  or  the  prominences  around  lapping  each 
other,  the  ligaments  will  tenaciously  hoh'  ;hem  in  that  condition. 
There  is,  therefore,  this  other  obstacl      j  be  overcome  simultane- 
ously with  the  forementioned.     Extension  will,  to  some  extent, 
reach  this,  but  the  surgeon  can  assist  very  materially  by  applying 
a  second  force.     After  extension  has  been  applied  for  some  time, 
and  the  muscles  are  quite  subdued,  then,  when  the  hones  are  locked, 
hy  lifting  the  head  of  the  hone  upon  which  the  extension  is  being 
made,  the  bones  will  the  more  easily  be  brought  together  at  the 


DISLOCATIONS. 


847 


joint.  In  this  way  the  head  of  the  femur  may  be  lifted  over  the 
brim  of  the  acetabulum.  The  proper  time  at  which  to  apply  this 
second  force  is  when  all  other  obstacles  are  overcome.  Sometimes 
a  sudden  jerk  or  quick  lift  will  secure  the  desired  end. 

Another  obstacle  which  may  have  to  be  encountered  is  that 
which  results  from  effusion  and  organization  of  plastic  matter,  by 
which  the  bones  have  become  bound  together  in  their  abnormal 
position.  If  these  be  of  long  standing,  to  overcome  them  is  most 
difficult,  perhaps  impossible.  Any  powerful  effort  to  reduce  a  dis- 
location  under  such  circumstances,  is  attended  often  with  extreme 
danger.  Results  the  most  disastrous  may  follow.  Inflammation, 
laceration  of  nerves  or  arteries,  followed  by  aneurisms,  are  not  un- 
hkely  results.  These  adhesions  may  be  supposed  to  exist  after 
there  has  been  considerable  inflammation,  whether  from  the  injury 
or  from  repeated  attempts  to  reduce  the  dislocation,  and  followed 
by  a  considerable  lapse  of  time.  In  such  cases,  where  it  is  thought 
advisable  to  try  to  effect  reduction,  the  adhesions  should  be  broken 
up  by  rotating  the  limb  repeatedly  before  extension  is  employed. 

A  very  difficult  obstacle  to  overcome  is  the  interposition  of  a 
tendon  or  ligament.  The  surgeon  can  never  be  sure  of  the  exist- 
ence  of  this  difficulty.  Sometimes  the  head  of  the  bone  is  forced 
through  a  capsular  ligament,  and  the  slit,  barely  large  enough  to 
allow  the  passage  of  the  head,  at  once  catches  it  as  a  button  is 
caught  in  a  button-hole.  There  will  be  reason  to  suspect  some 
such  obstruction,  when  a  seemingly  simple  case  of  dislocation  can 
not  be  reduced  by  the  ordinary  means.  In  such  cases  extension 
should  be  made  in  as  many  ways  as  practicable,  so  as  to  afford 
every  chance  for  the  head  to  be  extricated.  If  the  surgeon  be 
quite  certain  as  to  the  cause  of  the  difficulty,  he  may,  by  subcuta- 
neous section,  divide  the  parts.  To  insure  success,  however,  a 
perfect  knowledge  of  anatomy  as  well  as  of  the  pathology  is  indis- 
pensable. 

In  all  doubtful  cases,  whatever  the  cause  of  doubt,  when  it  is 
uncertain  whether  there  is  morbid  adhesions,  or  the  interposition 
of  any  substance,  the  surgeon  Dught  to  explain  to  the  patient  the 
nature  of  the  case,  and  the  doubtfulness  of  success,  so  that  he  may 
choose  for  himself  the  course  he  would  wish  to  be  pursued,  and 
thereby  bear  a  part  of  the  responsibility. 

Unlike  fractures,  dislocations,  when  reduced,  will,  in  almost  every 


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848 


PRINCIPLES    OF    SURGERY. 


case,  remain  reduced.    If  the  ligaments  have  been  torn,  a  retentive 
apparatus  may  be  required,  but  it  is  quite  the  exception.     Attel 
tion  must  be  given  to  prevent  inflammation.     Rest  of  the  joint  for 
a  time  must  be  secured.  "^ 

Compound  and  other  complicated  dislocations,  will  receive  in 
addition  to  the  treatment  of  dislocation,  the  same  treatment  a's  3 
given  to  complicated  fractures. 


CHAPTER    XLIII. 

Surgical  Affections  of  Arteries :  Inflammation-Coagulated  Fibrin  in  Vessel 
Pathology^    Aneurism:  Divisions-Varieties-Causes-Symptoms  and  1)7 
agnosis-Prognosis-Course-Eesults.  ymptoms  and  Di- 

^  Surgical  Affections  of  the  Arteries— Olassification.— The  affec 
tions  of  the  arteries  which  the  surgeon  may  be  called  upon  to  treat 
are  wounds,  inflammation,  deposit  of  fibrin  within  the  vessel  sun- 
puration,  ulceration,  contraction  of  the  vessel,  dilatation,  thicken- 
zng,  transformation;  and  arising  out  of  these,  the  important  dis- 
ease  of  aneurism. 

Wounds  of  Arteries.~^o  much  has  been  said  in  connection  with 
haemostatics,  respecting  wounds  of  the  arteries,  that  but  little  re- 
quires to  be  said  here.     Indeed,  it  is  only  necessary  to  speak  of 
those  wounds  which  only  partially  sever  the  vessel.     In  such  cases 
the  process  by  which  nature  closes  the  vessel  cannot  proceed,  and 
the  bleeding  consequently  continues.     The  surgeon  may  often 
cause  the  bleeding  to  stop  by  completely  dividing  the  artery.    If 
that  fail,  the  usual  course  will  be  pursued.      ( Vide  Hemostatics.) 
Pathology— Inflammation   of  the   ^^•^er^e«.— Inflammation   of 
the  arterial  coats  generally  assumes  the  chronic  form.     The  fact 
that  the  inner  coats  of  the  artery  are  not  supplied  with  vessels, 
but  are  supplied  otherwise  with  nutriment,  would  lead  us  to  expect 
that  the  phenomena  of  disease  therein  would  materially  differ  from 
disease  in  other  structures,  and  observation  corroborates  this  sup- 
position.     Indeed,  it  would  seem  that  the  so-called  inflammation, 
and  some  other  aflfections,  are  due  rather  to  certain  conditions  of 


SURGICAL    AFFECTIONS    OF    ARTEEIBS. 


849 


the  blood  than  to  the  ordinary  causes.  Whether  we  take  the  mem- 
brane lining  the  cavities  of  the  heart,  or  that  lining  a  remote  artery, 
the  appearance  of  the  tissue,  when  affected  by  what  is  called  arte- 
ritis, is  very  unlike  ordinary  inflammation.  The  early  and  most 
constant  product  of  this  disease  is  a  fibrinous  deposit,  which  may 
be  found  diffused  upon  the  inner  surface  of  the  vessel  to  a  greater 
or  less  extent.  Now,  the  absence  of  the  vasa  vasorum  warrants 
the  belief  that  this  deposit  must  be  derived  directly  from  the  cir- 
culating blood  as  it  passes  along.  There  are  certain  conditions  of 
the  blood  in  which  the  fibrin  will  readily  separate  from  it,  although 
in  seemingly  healthy  circulation,  and  be  deposited  upon  the  inner 
coat  of  the  artery  or  heart.  Any  prominent  point  will  be  the 
earlier  site  of  the  deposit.  It  is  often  seen  upon  the  cords  and 
valves  of  the  heart.  When  this  deposit  is  made  upon  the  arterial 
coats,  it  cannot  but  be  a  cause  of  embarrassment  to  the  vessel. 
The  arteries  continually  and  regularly  contract  and  dilate,  as  wave 
after  wave  passes  along  from  the  heart.  Now,  the  fibrin,  when 
deposited  upon  the  coats,  must  interfere  with  this  natural  action 
of  the  artery.  And  it  is  not  unlikely  that  the  symptoms  which 
characterize  this  disease  are  due  to  this  interference  with  the 
healthy  action  of  the  vessel.  That  is  to  say,  the  deposit  is  the 
first  step  in  the  disease,  and  is  the  cause  of  what  is  commonly 
designated  arteritis. 

The  pressure  of  coagulated  fibrin  upon  the  inner  coat  will  soon 
derange  normal  nutrition,  in  whatever  way  it  may  be  carried  on ; 
first  in  the  inner  coat,  and  soon  after  in  the  middle,  and  perhaps  in 
the  external  coat  also.  In  the  substa.-ce  of  the  coats  and  between 
them  will  also  be  deposited  fibrinous  material,  by  which  they  will 
be  thickened.  The  fibrin  thus  deposited  is  subject  to  the  same 
changes  as  when  deposited  elsewhere.  The  nature  of  these  changes 
will  depend  upon  the  character  of  the  fibrin,  the  manner  in  which 
it  may  be  affected,  and  the  vitality  with  which  it  is  endowed. 
Upon  these  will  depend  whether  organization  or  degeneration 
shall  follow,  or  whether  vain  attempts  at  organization  shall  be  fol- 
lowed by  degeneration,  or  by  a  transformation  of  both  adventitious 
and  natural  tissue. 

It  will  be  seen  that  two  general  pathological  results  may  follow 
the  deposit,  one  in  connection  with  the  fibrin  itself,  the  other  in 


ilijliliii 


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850 


PRINCIPLES    OF    SUEGERY. 


the  coats  of  the  vessel.     But  these  changes  will  ordinarily  pro- 
gress  simultaneously. 

One  very  common  effect  of  the  morbid  deposit  is  softening  of 
the  arterial  coats,  which  generally  are  thickened  at  the  same  time. 
A  further  result  of  the  softening  will  often  be  dilatation  of  the 
vessel.  The  coats  are  unable  to  resist  the  pressure  made  by  the 
constantly  coursing  blood,  and  so  gradually  yield  to  its  force.  If 
the  artery  be  to  a  considerable  extent  involved,  to  the  same  extent 
will  dilatation  take  place,  and  if  the  disease  be  limited,  so  will  the 
dilatation.  If  the  whole  circumference  be  affected,  then  dilatation 
of  the  whole  circumference  will  follow.  These  facts  are  mentioned 
particularly,  because  they  are  important  as  the  pathological  con- 
ditions of  certain  kinds  of  aneurisms. 

Again,  the  deposit  often  undergoes  certain  changes.    Perhaps,  in 
coagulating,  the  substance  is  converted  into  what  is  called  athero- 
ma, a  substance  composed  of  "  albuminous  and  earthy  particles 
of  crystalline  plates  of  cholesterine,  of  an  imperfect  fibrous  tex- 
ture, and  of  oil-globules."    (Gross.)     The  atheroma  thus  formed 
will  soon  involve  the  coats  of  the  vessel  in  the  same  disease.    With 
the  atheroma  there  is  often  softening ;  but  when  there  is  simply 
atheromatous  deposit,  dilatation  of  the  coats  may  take  place. 
Like  the  softening,  this  may  be  limited  in  extent,  or,  on  the  con- 
trary, an  extensive  surface  may  be  involved.     Often  there  will  be 
plates  of  this  substance  in  the  coats,  presenting  an  oval  or  rounded 
form.     In  connection  with  this  disease,  as  well  as  when  there  is 
softening,  there  is  not  unfrequently  ulceration  of  the  coats.    And 
when  the  tissue  composing  the  coats  is  destroyed  by  the  ulcerative 
process,  there  is  formed  an  aperture,  through  which  the  blood  will 
try  to  find  its  way  as  it  rolls  along  in  successive  waves.     The  ul- 
ceration may  be  limited  to  the  inner  coat,  or  it  may  extend  to  the 
middle  and  external  coats.     Here,  again,  we  see  how  aneurisms 
may  be  formed  from  arteritis.     The  blood  passes  through  the 
opening  made  by  ulceration,  and  gradually  causes  distension  of 
the  adjacent  tissues,  until  a  space— a  sac— is  formed  for  a  collec- 
tion of  blood. 

Then,  again,  the  adventitious  matter  may  be  transformed  into 
bone,  in  the  form  of  plates  of  the  size  of  a  pin's  head  or  a  finger- 
nail. Sometimes  the  whole  circumference  of  the  arterial  tube  is 
the  site  of  ossific  deposit.     This  is  more  commonly  seen  in  aged 


persons. 

entirely 

course,  m 

cannot  ti 

the  actioi 

is  likely  1 

the  plates 

bony  dep( 

dilatation 

up  ice. 

produce  i 

lowed  by 

Ulcerat 

be  confine 

When  the 

instead  of 

ternal  coa 

middle  cos 

from  the  e 

times  the  1 

distal  side 

again  into 

this  separa 

as  the  diss 

Again,  t 

tility,  may 

cumferencc 

the  vessel. 

its  course, 

thereby  inc 

condition  \\ 

kind  of  an( 

Fibrin,   ( 

changes.     '. 

without  leai 

completely 

pass  along. 

may  thereh 

deterioratin 


SURGICAL    AFFECTIONS    OF    ARTERIES. 


351 


persons.     I  have  seen  those  in  whom  the  arteries  of  the  arm  were 
entirely  bony,  and  consequently   there  was  no  pulsation.      Of 
course,  when  bony  matter  is  deposited  in  the  coats,  contraction 
cannot  take  place.     When  the  deposit  is  in  the  form  of  plates 
the  action  of  the  arterial  coats  will  be  embarrassed,  and  ulceration 
IS  likely  to  result  from  the  irritation  produced  by  the  margins  of 
the  plates  as  each  wave  of  blood  passes  along.     Not  unlikely,  the 
bony  deposit  is  at  first  uniform,  but  the  successive  contraction  and 
dilatation  breaks  it  up  into  several  plates,  as  a  swell  would  break 
up  ice.     It  is  then  that  the  edges  of  the  plates,  being  hard,  will 
produce  ulcerative  destruction  at  their  edges,  which  will  be  fol- 
lowed by  an  escape  of  blood,  and  thereafter  by  an  aneurism. 

Ulceration,  whether  resulting  from  one  cause  or  another,  may 
be  confined  to  the  internal  coat,  or  it  may  extend  to  the  others. 
A\hen  the  internal  alone  is  ulcerated,  the  blood  will  sometimes 
mstead  of  distending  the  outer  coats  into  a  sac,  separate  the  in- 
ternal coat  from  the  middle  for  some  distance;  likewise,  when  the 
middle  coat  is  also  perforated,  the  blood  may  separate  the  middle 
from  the  external  coat  to  an  equal  extent.     In  both  cases,  some- 
times the  blood  will  find,  at  a  point  some  distance  removed  on  the 
distal  Side,  an  ulcerated  opening,  by  which  it  will  gain  admittance 
again  into  the  circulation.     But  whether  this  is  the  case  or  not 
this  separation  of  the  coats  by  the  intrusion  of  the  blood  is  known 
as  the  dissectini/  aneurism. 

Again,  the  fibrin,  being  possessed  of  a  high  degree  of  contrac- 
tility, may,  especially  when  deposited  upon  or  in  the  whole  cir- 
cumference of  the  artery,  so  contract  as  to  diminish  the  calibre  of 
the  vessel.  In  consequence  of  this,  the  blood,  being  hindered  in 
Its  course,  will  press  upon  the  artery  at  the  cardiac  side,  and 
thereby  induce  dilatation,  especially  if  there  be  any  softening-a 
condition  which  may  coexist.  In  this  way  may  be  formed  another 
kind  of  aneurism. 

Fibrin,  deposited  in  the  arterial  coats,  may  undergo  other 
changes.  It  may  become  very  hard,  or  it  may  cause  thickening, 
without  leading  to  any  further  evil  results.  But  sometimes  it  may 
completely  close  up  the  artery,  so  that  the  bfood  can  no  longer 
pass  along.  The  results  of  this  may  be  very  serious.  A  limb 
may  thereby  be  deprived  of  blood.  Again,  the  clot  may  undergo 
deteriorating  changes— may  disintegrate,  and  the  small  particles, 


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352 


PRINCIPLES    OF    SURGERY. 


passing  along  for  a  certain  distance,  will  at  last  be  arrested  by  the 
smallness  of  the  vessel,  and  there  induce  inflammatory  action. 
Or  it  may  be  the  cause  of  a  more  serious— a  constitutional  affec- 
tion ;  it  may  constitute  a  blood  poison,  which  will  lead  to  most 
serious  diseases,  perhaps  pyemia  or  some  similar  affection. 

The  fibrin  deposited  may  possibly  degenerate  into  pus;  this, 
however,  is  more  likely  to  follow  wounds  which  have  involved  the 
arteries.  Sometimes  the  fibrin  will  coagulate,  and  completely  fill 
up  the  arterial  tube ;  but  in  the  middle  of  the  clot,  a  portion  will 
degenerate  into  pus.  And  thus  an  abscess  may  exist  within  the 
artery,  and  jef,  the  pus  never  find  an  entrance  into  the  circulation. 
Indeed,  the  fibrin  will  form  an  impassable  barrier,  by  which  the 
pus  will  be  prevented  from  entering  the  blood.  The  artery  being 
completely  destroyed,  the  abscess  will  take  the  ordinary  course, 
and  gradually  find  its  way  to  the  surface  of  the  body. 

Thus,  it  will  be  seen  that  the  disease  known  as  arteritis  cannot 
be  separated  from  the  various  other  affections  of  the  vessel ;  that, 
indeed,  it  stands  related  to  them  as  cause  to  effect. 

The  pathology  of  the  disease  seems  comparatively  plain ;  but  it 
is  most  insidious,  and  may  run  a  protracted  and  even  fatal  course 
without  a  knowledge  of  its  existence  being  had  by  the  individual 
or  his  medical  attendant.  From  certain  constitutional  defects  or 
tendencies,  such  diseases  may  be  inferred,  but  can  never  be  defi- 
nitely diagnosed. 

The  consideration  of  this  disease,  then,  but  prepares  us  for 
another,  whose  symptoms  are  patent;  a  disease  which,  of  all 
others  perhaps,  is  the  most  serious,  and  demands  the  most  discri- 
minating treatment.     I  refer  to  aneurisms. 

Aneuriama.—Jiy  an  aneurism  is  understood  a  sacculated  tumor 
communicating  with  an  artery,  and  filled  with  blood,  which  min- 
gles with  that  within  the  artery. 

Division. — Several  divisions  of  aneurisms  may  be  made.  First, 
into  true  and  fake.  A  true  aneurism  is  one  which  has  for  its  sac 
one  or  more  of  the  coats  of  the  artery.  A  false  aneurism  is  one 
which  has  neither  arterial  coat  for  a  covering,  but  whoso  sac  is 
formed  by  condensed  cellular  tissue.  The  former  is  the  result  of 
chronic  disease,  as  above  detailed,  and  is  the  most  common.  Tlic 
latter  is  generally  the  result  of  a  wound,  which  h«s  in  part  sovorod 
the  artery ;  but  it  may  also  arise  from  laceratioi  by  overstretch- 


SURGICAL    AFFECTIONS    OF    ARTERIES. 


353 


mg,  or  from  ulceration,  or  from  an  abscess.  The  solution  of  con- 
tmuity  in  the  structures  superficial  to  the  artery  may  become 
closed;  but  the  arterial  coats  do  not— cannot,  indeed,  from  the 
continuous  contraction  of  the  vessel.  Consequently,  the  blood 
gradually  finds  its  way  into  the  cellular  tissue,  which,  becoming 
condensed,  constitutes  the  sac  to  the  aneurism. 

Again,  aneurisms  are  divided  into  internal  and  external ;  that 
IS,  those  which  are  situated  in  the  cavities  of  the  body,  and  gene- 
rally receive  the  attention  of  the  physician ;  and  those  which  are 
external  to  the  body,  and  quite  within  the  reach  of  the  surgeon. 
Then  there  are  used  the  terms  mixed;  diffused;  circumscribed; 
dissecting;  varicose;  aneurismal  varix;  and  aneurism  by  anas- 
tomosis. 

Varieties.— There  are  a  variety  of  shapes  which  the  aneurismal 
tumor  may  present  in  the  course  of  its  formation  and  development. 
Thus,  It  may  be  sacciform,  or  fusiform,  or  cylindroid,  or  varix- 
hke.  The  form  which  it  assumes  will  depend,  in  the  first  place, 
upon  the  extent  of  arterial  tissue  involved;  then  upon  the  situa' 
tion  m  the  body;  and  then  upon  the  character  of  the  tissues 
agamst  which  the  tumor  will  press  as  it  grows  in  size.  In  the 
sacciform,  the  mouth  is  comparatively  small.  In  the  fusiform 
there  is  contraction  of  the  tube,  and  dilatation  above  it.  In  the 
cylindroid,  the  arterial  tube  is  generally  diluted. 

Number.--T\xere  is  generally  but  one  aneurism  existing  at  a 
time,  yet  occasionally  there  are  several  coexisting. 

Causes.— T\ie  great  predisposing  cause  has  been  fully  given,  but 
in  addition  the  following  may  be  mentioned:  The  male  sex;  pro- 
bably because  he  is  more  exposed  to  those  causes  of  constitutional 
disease.  The  period  of  life  between  thirty  and  fifty  is  considered 
a  predisposing  cause,  in  a  certain  sense.  The  lower  limb  is  pre- 
disposed to  aneurism.  Ti.e  laboring  class  is  more  frequently 
afiected,  also  probably  became  of  exposure.  Intemperance  is  said 
to  predispose  to  the  disease  ;  that  is,  to  those  diseases  which  result 
in  destruction  or  disease  of  the  arterial  structure.  Large  arteries 
are  more  frequently  the  sttc  of  disease. 

Exciting  Causes.— ^ome  sudden  and  relent  exertion  of  the  body 
or  Imb,  whereby  the  arterial  tissue  is     verstretched.  '  Again,  a 
wound  made  in  a  part  where  is  arterial  disease.     And  ulceration 
from  any  cause.  ' 

S8 


f> 


M 


354 


PRINCIPLES    OF    SURGERY. 


Symptoms  and  Diagnosis.— First,  there  is  the  elastic  pulsating 
swelling.     As  each  wave  of  blood  comes  sweeping  along,  the  blood 
rushes  into  the  sac  with  more  or  less  force,  and  strikes  upon  the 
outer  walls  thereof.     The  momentum  is  communicated  to  the  adja- 
cent tissue,  and  can  be  felt  by  the  finger  when  placed  immediately 
over  the  part.     However,  this  pulsation  is  not  always  a  reliable 
symptom,  for  the  same  will  be  felt  when  any  tumor  is  placed  over 
an  artery,  whereby  it  receives  the  impulse  of  the  arterial  current. 
When  the  blood  first  finds  its  way  into,  and  occupies  the  sac,  the 
tumor  will  be  more  particularly  elastic,  and  the  diagnosis  more 
certain ;  but  when  layers  of  coagulated  fibrin  have  successively 
formed  upon  the  inner  surface  of  the  sac,  the  elasticity  and  fluc- 
tuation will  be  absent  or  modified,  whereupon  it  will  bear  some 
resemblance  to  other  tumors.     An  aneurismal  tumor  may  be  re- 
duced in  size  by  placing  the  finger  upon  the  artery  at  the  cardiac 
side  of  the  tumor,  but  when  the  pressure  is  removed  the  tumor 
will  regain  at  once  its  previous  size.     This  is  a  valuable  diagnostic 
mark.     And  if  pressure  be  made  upon  the  distal  side  of  the  tumor, 
so  as  to  arrest  the  blood  flowing  from  the  aneurism,  the  tumor  will 
become  more  firm,  and  perhaps  increase  in  size.     Another  impor- 
tant  symptom  is  what  is  known  by  the  French  term  bruit  de  soufflet. 
This  peculiar  sound  is  produced  by  the  blood  as  it  is  hurried  into 
the  sac  through  its  mouth.     It  may  often  be  heard  by  simply 
placing  the  ear  over  the  part,  or  by  using  the  stethoscope.     In 
using  the  stethoscope,  however,  it  must  be  remembered  that  the 
pressure  of  the  instrument  may  so  act  upon  the  artery  through 
another  tumor,  as  to  lessen  the  current  and  give  rise  to  the  same 
sound.     If  the  tumor,  not  an  aneurism,  bo  overlying  the  artery, 
it  may  be  raised  by  the  hand  away  from  the  vessel,  whereupon  all 
resemblance  to  an  aneurism  will  at  onco  disappear.     But  when  it 
is  a  chronic  abscess  this  cannot  be  done. 

The  history  of  the  case  will  materially  assist  in  the  diagnosis. 
An  aneurism  contains  only  fluid  at  first,  and  is  soft;  after  a  wliilo 
it  becomes  more  firm.  But  an  ordinary  tumor  will  generally  be 
the  same  in  consistence  at  all  times,  Avtiile  an  abaccss  is  at  first 
hard,  and  sul)se(iuently  soft.  I  have  seen  a  psoas  abscess  mis- 
taken by  a  surgeon  for  an  aneurism,  and  by  another  surgeon,  for 
a  hernia.  Hut  the  liistory  and  behavior  of  a  hernia  are  very  un- 
like those  of  an  aneurism  ;  and  so  also  it  may  bo  said  of  a  chronic 


SURGICAL    AFFECTIONS    OP    ARTERIES.  355 

abscess.  Pain  is  often  present,  sometimes  is  very  great,  but  in  the 
latter  stages  the  tumor  may,  by  pressing  against  the  nerves,  in- 
duce paralysis.  The  integument  over  the  aneurism  may  remain 
natural,  but  if  it  approach  the  surface,  the  skin  will  gradually  lose 
Its  natural  appearance,  and  present  a  dark  red  or  livid  color 
Venous  circulation  in  the  limb  will  be  impeded,  leading  to  oedema 
and  a  reduction  of  the  temperature. 

Constitutional  Symptoms.-The  system  is  conscious  of  some  se- 
rious derangement  in  its  economy,  and  there  will  be  an  unexplain- 
able  state  of  depression,  bodily  and  mental,  for  which  the  patient 
cannot  account,  and  for  which,  there  seems  to  the  surgeon  no  ade- 
quate cause.  The  stomach  becomes  weak,  and  there  is  an  indif- 
ference or  actual  aversion  to  food.  Then  comes  great  restlessness 
sleepless  nights,  failing  strength,  and  perhaps  exhaustion. 

Prognosts.-Thk  must  always  be  given  with  extreme  caution. 
All  the  circumstances  of  the  case  must  be  fully  considored-the 
general  condition  of  the  patient,  the  predisposing  cause,  the  pre- 
sent sta^e  of  the  disease,  &c.  A  spontaneous  cure  may  take  place 
but  such  cases  are  rare.  Treatment  may  result  in  cure,  but  there 
are  many  failures. 

Coune  and  Eesuh-Pathohgy.-Tho  time  occupied  by  an 
aneurism  to  run  its  course  varies  very  much.  In  a  brief  period 
of  time  It  may  reach  a  fatal  end,  or  nature  alone  may  in  a  .short 
time  effect  a  perfect  cure.  On  the  contrary,  years  may  elapse 
before  the  final  termination  in  death.  The  course  of  the  disease 
18  by  no  means  uniform. 

The  several  ways  by  which  aneurisms  may  form  have  alreadv 
been  detailed.  In  order  to  follow  the  subsequent  progress  of  the 
tumor,  ,t  will  be  well  to  take  the  sacciform  aneurism,  which  ha. 
more  distinctly  a  mouth,  body,  and  fundus.  It  does  not  matter 
whether  it  be  a  true  or  a  false  aneurism.  At  every  pulsation  of 
the  heart,  the  blood  enters  the  sac.  The  quantity  which  enters 
and  the  force  will  depend  upon  the  size  of  the  mouth.  At  every 
pulsation  the  sac  is  fille.l  and  the  walls  exposed  to  pressure.  The 
tendency  is,  therefore,  to  gradual  enlarg,>ment  of  the  sac.  But 
the  pressure  made  by  the  blood  in  entering  is  not  diffused  over  the 
whole  innor  surface  of  the  sac,  but  is  directed  to  a  point  .lirectly 
opposite  the  mouth.  The  current  striking  this  point,  will  neces- 
sarily be  turned,  and  in  every  direction.     Now,  other  things  being 


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856 


PRINCIPLES    OF    SURGERY. 


equal,  the  sac  will  enlarge  at  the  point  where  the  current  strikes 
the  wall.  But  the  place  of  dilatation  does  not  depend  alone  upon 
the  force  of  the  current,  but  also  upon  the  firmness  of  the  opposintr 
structures  without  the  sac.  At  those  places  external  to  the  sac 
where  the  tissue  is  yielding,  there  will  dilatation  the  more  readily 
take  place ;  and  on  the  contrary,  where  it  is  unyielding,  there  the 
dilatation  will  be  stayed.  Hence  it  will  be  seen,  dilatation  may 
take  place  in  any  direction.  And  practically  such  is  found  to  oc- 
cur. Sometimes  the  tumor  extends  to  the  distal  side,  and  some- 
times towards  the  cardiac  side,  but  the  latter  is  less  frequent. 

From  the  above  it  will  be  seen  that  there  is  at  all  times  within 
the  sac  a  direct  current  of  blood,  and  several  indirect  currents 
formed  by  the  blood  regurgitating  after  striking  the  wall  of  the 
sac.     It  follows,  in  consequence,  that  the  blood  will  in  some  places 
be  in  a  more  quiescent  state  than  in  others  ;  that  although  it  is 
agitated,  it  is  not  moving  so  rapidly.     Now,  in  those  places  of  the 
sac  where  the  blood  is  comparatively  at  rest,  the  tendency  of  that 
fluid  to  coagulate  will  begin  and  continue  to  manifest  itself.    Sepa- 
rated  from  the  volume  of  blood,  the  fibrin  will  part  from  the  other 
constituents,  and  coagulate  upon   the  inner  surface  of  the  sac. 
Thus  it  will  be  found  that  layer  after  layer  will  form  in  that  por- 
tion of  the  sac  where  there  is  the  least  moving  of  the  blood.     In- 
deed, upon  the  whole  surface,  deposition  may  gradually  take  place. 
Nature,  true  to  herself,  is  even  here  acting  by  means  of  the  fibrin, 
to  arrest  the  course  of  disease,  and  to  effect  repair.     And  occa- 
sionally  the  cfi'ort  is  successful ;  the  sac  being  gradually  filled  by 
successive  layers  of  coagulated  fibrin,  and  the  blood  no  longer  find- 
ing space  to  enter.     But  this  process  is  frequently  interrupted,  if 
not  quite  turned  aside,  by  the  power  of  disease.     Sometimes  tiie 
clots  of  fibrin  are  detached  and  moved  about  in  the  sac  by  the  cur- 
rents of  bio  -:1.     These  clots  may  pass  out  into  the  arterial  current, 
and  being  carried  on,  give  rise  to  other  mischief.     Or  one  may  be 
caught  in  the  mouth  of  the  sac  as  it  is  being  carried  out,  and  there 
remain.     When  this  hiippens,  it  forms  a  favorable  obstruction  to 
the  inrushing  blood,  and  upon  it  fif)iin  will  be  deposited,  generally 
until  the  mouth  is  completely  closed.     Thus  a  cure  may  be  accom- 
plished.    There  are  other  ways  by  which  a  spontaneous  cure  may 
be  eflfected.     As  the  aneurismal  sac  enlarges,  it  may  press  upon 
the  artery,  either  to  the  cardiac  or  the  distal  side,  or  more  directly 


SUROIOAl    APFECTIONS    OP    AETBEIES.  857 

npon  the  vesael.     It  will  be  understood,  from  what  has  been  said 
hat  to  lessen  the  current  of  blood-to  diminish  its  fore  . is,"  off'; 
advantages  for  cure.     Hence  it  is  that  the  aneurismal  tumor  re 

ted     Al-„r    '"■':'  '     "f'  "'  ""■'"^  itself  becomes  oblitera- 
ted.    Again,  the  rapid  growth  of  the  tumor  may  give  rise  to  in- 
flammatory  action  in  the  part,  involving  more  or  lesf  of  tl  e  ae  bu 
sufficiently  great  to  assist  in  the  elaboration  of  the  adhe  ve  Lph 

runs  so  high  as  to  cause  occlusion  of  the  artery,  and  the  formation 
of  an  abscess,  by  which  the  whole  morbid  n.ass  s  got  rid  „  But 
this  result  IS  very  rare.  Sometimes  the  aneurism'  becoming  ^^ 
Me,  that  IS  a  true  aneurism,  after  a  time,  becoming  false  frtm 
the  original  sac  being  ruptured  or  ulcerated,  the  escap  d  W^od 
will  coagulate  around  the  vessel,  and  thereby    ffect  a  cure    but  n 

:ma,[i™r ""'  ■'™'*^  "-'^-  -' ^e-Hand::vV: 

re,'/h"trr"'°"\''"''''  ■"  ""'  '^■""'^-  ""^  »»  "-edial  measures 
the  body,  or  to  some  cavity  within  the  body.  The  method  of  »„ 
preach  resembles  that  of  the  pointing  of  an'Lbscess.  «  wL/e  the" 
aneurism  opens  into  a  serous  cavity,  the  membrane  thereof  wHlt 
found  lacerated.  When  it  bursts  through  the  skin  or  mucous  mm 
brane,  the  te,ue  will  be  found  attenuated,  and  that  finally  a  sma^i 
opening  had  been  made  by  absorplion."  """"J.  »  small 


1  ;■      '    '  ■'.    »  I 


ill 


'  1 1 


'■  l--ii'--  tj 


868 


PRINCIPLES    OF    SURGERY. 


CHAPTERXLIV. 

Treatment  of  Aneurisms:  Three  General  Methods— Compression— Digital 
Compression— Treat  by  Flexion— By  Manipulation— By  Ligature— By 
Hunter's  Method — By  Brasdor's- By  Wardrop's— by  Injections— By  a  Cur- 
rent of  Electricity.  Varieties  :  Varicose— Arterio-venous  —  Treatment. 
Aneurism  by  Anastomosis. 


Treatment. — We  have  seen  in  every  instance  where  spontaneous 
cure  is  effected,  that  the  fibrin  acted  an  essential  part,  and  that 
without  it  cure  could  not  seemingly  have  taken  place. 

The  surgeon  in  treating  aneurism  must  take  the  infallible  guide 
which  the  operation  of  nature  gives  to  him.  It  has  been  seen  that 
in  or  dor  to  coagulation  of  fibrin  within  the  sac,  the  blood  must  be  in 
a  comparatively  quiescent  state,  not  absolutely  at  rest,  but  so  little 
agitated  that  gradual  deposition  of  fibrin  may  take  place.  And  it 
is  fibrin  alone  that  is  required  ;  coagulated  blood  is  not  so  firm,  and 
more  especially,  some  of  its  elements  may  decompose.  It  is  fibrin 
alone  that  can  effectually  close  up  the  sac.  Consequently,  to  se- 
cure the  desired  end,  the  blood  should  not  be  altogether  cut  off 
from  the  sac.  On  this  point  I  would  be  specific,  as  it  is  not  a  fact 
generally  recognized. 

There  are  three  general  methods  of  treating  aneurisms.  By 
the  first,  the  circulation  of  blood  is  retarded  in  its  flow  to  the  sac. 
By  the  second,  the  blood  is  entirely  arrested.  By  the  third,  some- 
thing is  administered  generally/  or  applied  locally  to  cause  coagula- 
tion of  the  blood.  In  the  first  method,  pressure  is  applied ;  in  the 
second,  a  ligature  is  used  to  the  vessel ;  while  in  the  third,  some 
medicine  is  exhibited.  Of  these  three  modes,  the  second  is  least 
deserving  of  recommendation.  Independently  of  the  danger  at- 
tending the  operation,  which  is  not  a  little,  it  is  abundantly  plain 
that  the  preferable  mode  of  treatment  is  by  pressure,  and  at  the 
same  time  such  other  means  as  will  retn>:1l  the  flow  of  blood  into 
the  sac.  Because,  therobythe  volume  oi  ihe  blood  is  not  so  great 
as  to  prevent  coagulation,  while  there  ; .  supplied  the  necessary 
quantit;^  '  f  fibrin  to  form  the  clot. 


TREATMENT    OP    ANEURISMS. 


359 


There  are  two  general  ways  by  which  the  arterial  flow  may  be 
lessened  in  the  affected  part.  One  is  by  acting  on  the  heart  it- 
self-controlhng  its  action ;  the  other  is  by  local  means,  as  pres- 
sure  upon  the  artery.  Anything  that  tends  to  increase  the  heart's 
action  must  be  steadily  avoided.  Bland  diet  and  drink.  Rest  of 
body  and  mind,  are  important  ingredients  in  the  general  treat- 
ment.  And  then  the  internal  administration  of  drugs  which  will 
reduce  the  action  of  the  circulation,  as  digitalis.  These  constitu- 
tional  means  are  always  important;  but  to  the  physician,  in  the 
treatment  of  internal  aneurism,  they  constitute  the  sole  agents  to 
which  he  may  resort.  ° 

Prmwm-The  surgeon  in  treating  external  aneurism  will,  in 
the  first  instance,  try  local  treatment  by  pressure.  There  are 
several  methods  by  which  this  can  be  applied.  By  bandaging  the 
Ivmh,  commencing  at  the  extremity  ;  by  direct  presmre  upon  the 
tumor ;  hy  pressure  to  the  artery  at  the  cardiac,  or  at  the  distal  side 
of  the  tumor  with  the  instrument;  by  digital  compression,  and  by 
flexion.  And,  failing  in  these,  by  the  application  of  a  ligature  to 
the  artery.  "^ 

With  respect  to  the  first,  bandaging,  there  can  be  no  doubt  that 

when  prop^-ly  applied,  it  will,  by  keeping  the  limb  in  a  compara- 

ive  state  of  rest,  and  by  lessening  the  arterial  flow  through  the 

hmb  and  especially  into  the  aneurismal  sac,  promote  the  deposit 

ot  hbrm  in  laminae  upon  the  inner  surface  of  the  sac. 

Pressure  directly  applied  to  the  tumor,  unless  at  the  same  time 
to  the  artery  above,  is  of  doubtful  utility.  It  cannot  be  recom- 
mended. But  pressure  upon  the  cardiac  side  of  the  tumor  cannot 
be  too  highly  spoken  of.  By  this  is  commonly  understood  instru- 
mental pressure,  which  is  quite  different  from  digital  compression 
Ihis  treatment  is  based  upon  the  correct  principle,  that  a  compa- 
ratively slow  formation  of  a  fibrinous  clot,  is  the  surer  way  to  effect 
a  cure.  *^ 

The  method  of  treatment  by  compression  is  of  old  date,  but  to 
Irish  surgeons  of  comparatively  recent  date,  must  principally  be 
given  the  credit  of  proving  the  usefulness  of  the  system.  It  is 
always  important  to  so  use  the  pressure  as  to  avoid  arresting  the 
venous  flow.  "  The  compressors  now  in  use  are  made  on  the  prin- 
ciple of  exerting  pressure  upon  a  small  space,  without  any  circular 
constriction  of  the  limb.     They  consist  of  a  plate  or  trough,  whi.l. 


:.\i'\. 


'■\  '  ' 


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1  »■  '• 


iiil  ^'^ 


thrill! 

r 


irn 


360 


PRINCIPLES    OF    SURGERY. 


is  applied  to  the  lower  surface  of  the  thigh"  (supposing  it  to  be  a 
popliteal  aneurism),  "  at  the  point  opposite  to  the  artery,  and  a 
pad  supported  on  this  plate  by  a  strong  lever  or  arm,  and  mova- 
ble  in  all  directions.     The  lever  stands  well  away  from  the  thigh, 
and  the  instrument  is  kept  in  position  by  the  compression  which 
it  exercises.     When  applied,  it  is  screwed  down  upon  the  artery 
until  the  sensation  communicated  by  the  aneurism  to  the  hand  is 
considerably  lessened,  say  diminished  about  one-half,  and  is  left 
so  until  the  patient  is  sensible  of  inconvenience  from  it."     And 
"  it  is  better  to  commence  with  very  mild  pressure,  to  change  the 
place  of  its  application  frequently,  and  to  give  the  patient  such 
intervals  of  complete  repose  as  may  refresh  his  spirits  and  procure 
him  good  sleep.     The  management  of  the  compressor  should  be 
intrusted  to  some  one  who  knows  the  course  of  the  artery,  and 
can  judge  of  the  direction  in  which  pressure  should  be  applied  to 
command  it.     The  course  of  the  artery  can  be  indicated  by  a  line 
drawn  down  the  limb  with  caustic,  and  any  intelligent  patient  or 
nurse  soon  learns  where  to  apply  the  pad."    (System  of  Surgery.) 
The  pressure  should  never  be  continued  so  long  in  one  place  as  to 
incur  the  slightest  risk  of  sloughing.     Fortunately  incessant  pres- 
sure is  not  necessary. 

"  The  time  required  for  the  success  of  the  compression  treat- 
ment varies  remarkably.     In  twenty-six  successful  cases  reported 
in  the  Medical  Times  and  Gazette,  the  time  varied  from  sixty  hours 
to  eight  months,  the  average  being  nineteen  days.    In  some  of  the 
protracted  cases  the  cause  of  the  delay  has  been  the  inefficient  way 
in  which  the  treatment  has  been  carried  out.     Thus  in  the  case  of 
a  young  woman  who  was  under  Mr.  Prescott  Hewitt's  care,  in  St. 
Joseph's  Hospital,  on  account  of  popliteal  aneurism,  some  years 
ago,  the  disease  remained  stationary,  notwithstanding  the  constant 
application  of  pressure  for  months,  but  was  cured  in  a  few  days 
after  her  transference  to  the  care  of  a  different  nurse.     It  was  dis- 
covered that  the  previous  attendant  had  been  in  the  habit  of  allow- 
ing her  to  remove  the  instrument  and  walk  about  the  ward.    Usu- 
ally when  a  limb  is  examined  after  the  successful  use  of  compres- 
sion, the  artery  above  the  tumor  shows  no  trace  of  its  action. 
The  tumor  is  generally  quite  firm,  being  filled   with   laminated 
coagulum ;  but  sometimes  a  channel  is  seen,  through  which  circu- 
lation has  gone  on  in  it.     All  this  will  be  seen  to  be  identical  with 


TREATMENT    OP    ANEURISMS. 


861 


spontaneous  cure.  Enlarged  anastomosing  arteries  are  generally 
discovered,  and  this  enlargement  is  usually  and  rightly  regarded 
as  one  of  the  earliest  and  best  symptoms  of  commencing  cure." 
(System  of  Surgery.) 

"  One  great  advantage,  however,  of  the  treatment  by  compres- 
sion is,  that  when  it  faiFs  it  seldom  fails  totally,  for  if  it  does  not 
succeed  in  curing  the  aneurism,  yet  in  almost  all  cases  it  places 
the  disease  under  more  favorable  conditions  for  cure.  The  obvi- 
ous reason  is,  that  it  produces  enlargement  of  the  collateral  ves- 
sels, and  thus  obviates  the  tendency  to  gangrene." 

"As  to  pressure  on  the  distal  side  of  the  sac,  I  have  nothing  to 
say,  never  having  seen  a  case  in  which  there  was  any  temptation 
to  use  it.  Its  uncertainty  and  danger  are  so  apparent,  that  it 
should  never  be  used  where  compression  or  ligature  can  be  applied 
above  the  tumor;  but  in  aneurisms  at  the  root  of  the  neck,  it  may 
be  in  some  cases  worthy  of  a  cautious  trial."  (System  of  Surgery 
— T.  Holmes.) 

Digital  Compression.— '^ '^h^  treatment  of  aneurism  by  digital 
compression  is  of  .very  recent  origin.  It  has  sprung  directly  from 
the  successes,  and  it  must  be  said,  also  from  the  failures  of  the 
treatment  by  mechaqical  compression.  The  first  recorded  case  in 
which  digital  compression  was  successfully  employed  for  aneurism 
appears  to  be  that  of  a  patient  treated  by  Mr.  Greatrex,  in  May, 
1844,  and  whose  case  was  recorded  by  that  surgeon  in  the  Medico- 
Chirurgical  Transactions  for  1845."  Compression  by  the  fingers 
was  used  in  conjunction  with  the  tourniquet. 

But  in  1848,  Dr.  Knight,  of  New  Haven,  United  States,  for 
the  first  time  employed  compression  of  the  femoral  by  the  fingers 
as  the  sole  means  of  cure.  "  He  obtained  the  help  of  a  number 
of  assistants,  who  relieved  each  other,  two  and  two  every  half 
hour,  maintaining  continued  pressure  to  an  extent  which  arrested 
pulsation  in  the  tumor.  At  the  end  of  forty  hours,  the  tumor  was 
one-thir.l  smaller,  hard,  and  pulseless.  Compression  was  stopped, 
the  cure  was  complete,  and  four  months  afterwards  the  tumor 
could  hardly  be  felt. 

"  The  merit  of  strongly  insisting  upon  the  value  of  digital  com- 
pression, and  studying  its  applications  to  surgical  treatment,  with 
a  success  which  fixed  the  attention  of  European  surgeons,  is  un- 
doubtedly due  to  Vanzetti  (Professor  of  Padua).     These  early 


1  ¥  ^' 


i  i; 


'i  Hi!: 


362 


PRINCIPLES    OF    SURGERY. 


successes  were  speedily  followed  by  others  equally  remarkable 
In  July,  1856,  a  female  patient  came  under  the  care  of  Professor 
Giappi,  of  Padua,  the  subject  of  aneurism  of  the  ophthalmic 
artery.     The  case  was  one  of  great  severity.     The  eye  projected 
on  to  the  cheek ;  it  was  motionless  ;  the  cornea  was  infiltrated  and 
opaque :   th..  sight  was  gone.      The  pulsating  aneurismal  tumor 
could  be  feit  by  introducing  the  finger  between  the  globe  of  the 
eye  and  the  roof  of  the  orbit;  the  bruit  could  be  heard  loudly 
The  carotid  was  compressed,  for  periods  of  a  minute  or  two  and 
with  frequent  intervals,  by  the  convalescents  of  the  ward  and  by  the 
patient  herself.     Pressure  continued  for  more  than  a  minute  pro 
duced  fainting.     NevertboU  s.,  ..  the  end  of  one  day  there  was  a 
visible  improvement,  and  at  the  end  of  f  nr  day.  all  pulsation  had 
ceased.     Four  months  afterwards,  the  eye  rested  and  moved  natu- 
rally m  the  orbit;  vision  was  restored,  the  patient  remaining  only 
somewhat  short-sighted,  and  with  the  pupil  slightly  dilated      A 
second  case,  in  which  a  formidable  aneurism  of  the  ophthalmic 
artery,  m  a  patient  the  subject  of  aortic  and  cardiac  disease,  was 
cured  by  digital  compression,  was  published  in  1858,  byDrs 
Vanzetti    and   Scaramuzza.      Intermittent   compression   of   the 
carotid  by  the  finger  was  here  also  employed  for  five  minutes  at  a 
time,  and  cure  was  effected  by  seven  hours  and  twenty  minutes  of 
compression,  spread  over  eighteen  days.    These  brilliant  successes 
real  triumphs  of  conservative  surgery,  supported  as  they  were  by 
abundant  and  irrefragable  testimony,  sufficed  to  place  digital  com- 
pression amongst  the  most  precious  resources  of  surgery  in  the 
treatment  of  external  aneurism. 

"The  subsequent  experience  of  surgeons  who  have  employed 
this  treatment  since  Vanzetti,  affords  numerous  instances  of  cure 
unrivalled  for  simplicity,  painlessness,  ease,  and  rapidity,  in  the 
records  of  the  treatment  of  aneurism  by  other  means. 

"It  has  been  objected  to  the  digita'  mode  of  treatment  that, 
from  the  considerable  nunrber  of  assis  ants  required,  it  could  only 
be  carried  out  in  certain  large  hospita.s,  and  then  at  great  inconve- 
nience.  The  objection  is,  however,  of  no  great  force;  for,  under 
such  circumstances,  assistants  are  rarely  wanting,  and  in  more 
than  one  case  the  patient  has  been  able  successfully  to  complete  ' 
the  cure  by  the  unaided  pressure  of  his  own  fingers.  And  although 
a  full  staff  of  eight  or  ten  assistants  are  sometimes  required,  yet  a 


TREATMENT    OF    ANEURISMS. 


863 


smaller  number  will  often  suffice.  Most  surgeons  are,  I  think 
agreed  that  the  pressure  should,  as  a  rule,  be  intermittent.  The 
opposite  practice  produces  occasionally  some  rapid  and  brilliant 
cures;  but  it  tends  to  procure  coagulation  en  masse  of  the  con- 
tents of  the  aneurismal  sac,  with  its  accompanying  dangers,  while 
the  znterniittent  treatment  favors  the  safer  form  of  laminated 
fibrinous  deposition."     (System  of  Surgery-E.  Hart.) 

Ihe  foregoing  quotations  are  so  much  to  the  point,  that  no  ex- 
cuse  need  be  offered  for  introducing  them  here 

This  principle  of  pressure,  digital  or  otherwise,  is  no  doubt  ca- 
pable of  being  applied  to  cases  which  heretofore  have  been  deemed 

niiri««!i  •  """"^  f  '""'^''^^  ''^-     ^"  '^'  London  Lancet, 
June  nth,  1864,  is  recorded  a  "case  of  aneurism  of  the  abdominal 

aorta,  which  was  cured  by  compression  of  the  artery  immediately 
above  the  tumor,"  by  Dr.  W.  Murray,  of  Newcastle.     Pressure 
was   applied   by   the   ordinary  horseshoe  tourniquet,  above   the 
tumor,  one  blade  over  the  spine.     The  patient  was  put  under  the 
influence  of  chloroform,  because  of  the  severe  pain  attending  the 
use  of  pressure.     It  was  continued  two  hours,  the  first  time,  with- 
out any  apparent  result.    Three  days  after,  it  was  again  employed, 
and  continued  for  five  hours ;  but  during  that  time  the  instrument 
would  occasionally  be  displaced.     "  Its  removal  showed  that  now 
very  little  pulsation  existed  in  the  tumor."    "  Beyond  a  little  shiv- 
ering  and  numbness,  with  coldness  of  the  feet  and  legs,  nothing 
of  an  untoward  nature  followed.     In  the  evening,  after  a  mosi 
careful  examination,  I  failed  to  detect  the  slightest  pulsation  in 
the  tumor  or  in  the  aorta  below  it."     -  S^x  days  after,  collateral 
circulation  was  so  fully  established  that  the  patient  could  walk 
with  but  slight  sensation  of  numbness.     Within  a  fortnight    he 
was  seemingly  quite  well."     Now,  it  must  be  confessed  that  'this 
IS  a  wonderful  case.     It  was  reported  to  the  Royal  Medical  and 
Chirurgical  Society,  and  the  truthfulness  is  fully  attested  as  to 
diagnos     and  the  result.     Certainly,  the  march  of  our  profession 
IS  onw;     I,  and  still  onward. 

Treatment  by  Flezion.-Agam,  I  prefer  to  give  the  admirable 
account  of  this  mode  found  in  the  System  of  Surgery  bv  T 
Holmes:  ts    j     j 

"  The  simple  bandaging  of  the  limb  in  acute  flexion,  the  patient 
being  kept  at  rest,  may  occasionally  succeed  in  curing  aneurisms 


m> 


864 


PRINCIPLES    OP    SURGERY. 


Situated  at  the  bend  of  the  limb,  as  in  the  popliteal  space  or  the 
elbow,  and  possibly  in  the  groin.     This  plan  of  cure  had  been 
previously  tried,  but  the  merit  of  first  demonstrating  its  success  is 
fairly  due  to  iMr.  Ernest  Hart.     All  that  is  requisite  in  this  treat 
ment,  is  to  bandage  the  limb,  from  the  toes  nearly  to  the  knee 
with  a  roller,  and  then  to  turn  the  roller  round  the  thigh  flexed  at 
an  acute  angle ;  the  limb  should  then  be  bent  upon  the  pelvis  and 
the  knee  rested  against  a  pillow.     In  Mr.  Hart's  case,  the'cure 
had  made  considerable  advance  after  the  first  day  of  the  treat 
ment,  and  was  complete  on  the  fourth  day ;  on  the  seventh  the" 
patient  was  moving  about.  ' 

"  The  cases  best  adapted  for  the  trial  of  flexion  are  the  simplest 
In  those  cases  where  the  tumor  is  not  of  very  large  size,  where 
the  parts  covering  it  are  not  much  inflamed,  nor  the  joint  involved 
and  where,  as  far  as  can  be  ascertained,  the  tumor  is  seated  on  the 
superficial  face  of  the  artery,  we  may  anticipate  benefit  from  flex 
ion      If  the  flexion  of  the  limb  entirely,  or  almost  entirely  sus- 
pends the  pulsation  of  the  bruit,  this  treatment  may  be  trusted  by 
Itself;   otherwise,  a  compressor  must  be  applied  to  the  artery 
above,  in  aid  of  the  flexion.     But  the  compression  need  not    in 
such  a  case,  be   applied  with  nearly  the  same  severity  which 
would  be  demanded  in  an  ordinary  case.     A  very  slight  amount 
of  pressure   will    often   serve ;    and   if  the   only   advantage  of 
this  simple  and  nearly  painless   proceeding  were  to  spare  the 
patient  the  annoyance  of  severe  pressure,  it  would  be  no  slight 
one.     There  are,  however,  many  cases  in  which  the  aneurism  will 
be  entirely  cured  by  it,  without  the  smallest  risk  either  to  life  or 
limb." 

Treatment  hy  Manipulation.— ^he  principle  upon  which  this 
method  IS  based,  is  by  breaking  up  the  laminated  clots  of  fibrin  a 
piece  of  which  may  be  caught  in  the  mouth  of  the  sac,  and  'so 
lead  to  Its  complete  closure;  or  it  may  be  suflSciently  large  to 
occlude  the  artery  on  the  distal  side,  whereby  a  cure  may  be 
effected.  But  this  procedure  often  fails,  and  is  attended  with 
much  risk  from  the  pieces  of  clotted  fibrin  passing  into  the  circu- 
lation. 

Treatment  hy  the  Ligature.-The  application  of  a  ligature  to 
the  artery  for  the  cure  of  aneurism  should  not  be  hastily  resorted 


TREATMENT    OF    ANEURISMS. 


365 


to,  not  until  all  other  means  have  failed,  and  there  must  be  a  rea- 
sonable prospect  of  success  following  the  opferation. 

There  are  three  general  ways  familiar  to  surgeons,  called  re- 
spectively Hunter's,  Brasdor's,  and  Wardrop's.     Hunter's  method 
consists  in  applying  the  ligature  upon  the  cardiac  side,  at  some 
distance  from  the  tumor.     It  will  be  remembered  that  in  the  true 
aneurism  the  arterial  coats  are  very  generally  in  a  state  of  chronic 
disease.     Now,  to  cut  down  and  apply  a  ligature  to  a  vessel  thus 
diseased,  would  be  to  increase  the  danger  already  so  imminent  to 
the  life  of  the  patient.     Hunter  conceived  the  idea  of  obviating 
this  danger  by  ligating  the  vessel  at  a  point  as  far  removed  from 
the  tumor  as  can  be  done,  so  as  to  lessen  the  probability  of  the 
coats  being  involved  in  disease.     It  is  true  Hunter  failed  in  his 
operation,  but  the  failure  was  due  to  the  flat  ligature  which  he  em- 
ployed. 

Before  proceeding  to  apply  a  ligature,  the  following  points  must 
be  duly  considered.     First,  there  must  be  collateral  circulation. 
To  secure  this  there  must  be  a  branch  above  the  place  of  ligation 
which  anastomoses  with  a  branch  below  the  aneurism.     Through 
these  the  part  beyond  will  be  supplied  with  blood,  and  if  such  do 
not  exist,  that  part  will  perish  for  want  of  blood.    These  branches 
will  very  soon  accommodate.themselves  to  the  increased  quantity  of 
blood  which  will  seek  to  flow  through  them.    Again,  there  requires 
to  be  a  space  between  the  place  at  which  the  ligature  is  applied 
and  the  branch  above,  in  which  a  plug  of  fibrin  may  form,  and  by 
which  the  tube  will  be  made  impervious.     Another  thing  to  be 
considered  before  operating,  is  whether  there  is  a  second  aneurism 
because  such  would  indicate  extensive  disease  of  the  arterial  tis- 
sue, and  the  operation  could  not  be  considered  warrantable.    And 
again,  if  the  patient  be  aged,  but  little  hope  may  be  anticipated 
or  recovery.  *^ 

In  performing  the  operation  the  principles  detailed  in  connec 
tion  with  the  subject  of  Haemostatics  will  be  observed. 

The  immediate  eff-ect  upon  the  aneurism  is  to  cause  its  partial 
or  entire  disappearance,  the  walls  being  more  or  less  collapsed. 
As  collateral  circulation  is  established,  the  blood  will  flow  up  and 
into  the  sac,  to  some  extent.  But  this  cannot  be  regarded  as  an 
untoward  occurrence,  for  as  we  have  seen,  a  limited  supply  of 
fibrin  conduces  to  the  formation  of  a  fibrinous  clot.     Yet  not  un- 


366 


PRINCIPLES    OP    SURGERY. 


likely,  if  the  sac  remained  empty,  its  walls  might  unite  by  adhe- 
sion, as  sometimes  follows  the  emptying  of  an  abscess. 

Brasdor'a  Operation. — Sometimes  the  location  of  the  aneurism 
is  such  that  the  ligature  cannot  be  applied  on  the  cardiac  side. 
When  such  is  the  case  Brasdor'a  operation  is  sometimes  per- 
formed ;  that  is,  the  ligature  is  applied  to  the  capillary  side  of  the 
tumor.  This  stoppage  of  the  arterial  current  below  the  aneurism 
will  very  soon  lead  to  a  more  rapid  deposit  of  fibrin  within  the  sac 
and  ultimately  to  a  cure. 

Wardrop'8  Operation  is  occasionally  adopted.     It  is  only  per- 
formed  when  the  aneurism  is  placed  near  a  bifurcation,  and  a  liga- 
ture cannot  be  put  on  at  the  cardiac  side.     A  nd  consequently  it 
is  applied  to  one  of  the  branches.     The  result  aimed  at  is  a  lessen- 
^  ing  of  the  arterial  flow  into  the  sac,  and  thereby  the  cure. 

Treatment  by  Injections. — This  is  adopted  to  produce  coagula- 
tion of  the  blood.  The  agents  more  commonly  employed  are  ace- 
tate of  lead  and  the  tincture  of  iron  ;  the  perchloride  is  highly  ap- 
proved. The  operation  is  attended  with  some  danger,  and  although 
coagulation  of  blood  in  the  sac  is  the  immediate  result,  yet  the  cure 
is*  very  uncertain.  Very  serious  inflammation  often  follows  the 
injection.  This,  if  controlled,  may  itself  lead  to  obliteration  of  the 
tumor.  The  fact  that  the  aneurism  may  be  treated  b}'  compression 
in  many  cases  will  prevent  the  frequent  adoption  of  this  course. 

To  perform  the  operation  "  the  best  instrument  for  the  purpose 
is  the  small  graduated  syringe,  with  screw  piston  and  glass  body, 
made  for  the  purpose  by  most  instrument  makers,  and  also  used 
for  subcutaneous  injections.  In  performing  the  injection,  it  is 
necessary  first  to  establish  accurate  comprcHsion  of  the  artery 
above  and  below  the  tumor,  so  as  completely  to  arrest  the  blood 
in  it.  The  pointed  trocar  is  plunged  perpendicularly  into  the  tu- 
mor, care  being  taken  on  the  one  hand  to  enter  the  cavity,  and  on 
the  other  not  to  transfix  it,  both  of  which  accidents  have  happened 
to  experienced  operators.  The  success  of  the  step  is  indicated  by 
the  issue  of  ar<ma/ blood,  an  indication  which  should  be  looked 
for.  The  canula  is  now  screwed  on  to  the  trocar,  and  so  uiuch  of 
its  contents  as  may  be  thought  necessary,  ejected  by  successive 
turns  of  the  piston.  The  eomprcssion  of  the  artery  on  the  cardiac 
Bide  of  the  sac  should  e  continued  for  an  hour."  (System  cf  Sur- 
gery—E.  Hart.) 


TREATMENT    OF    ANEURISMS. 


367 


Treatment  bypassing  a  current  of  electricity  into  the  sac,  has 
been  successful,  but  is  not  deserving  of  more  credit  than  that  just 
given  to  the  injecting  of  coagulating  fluid.  The  clot  is  formed 
suddenly,  and  will  likely  soften  after  a  little.  Inflammation  is 
also  a  frequent  effect. 

Treatment  of  aneurism  by  medicines  internally. —Drugs  may  be 
given  to  cause  coagulation,  and  at  the  same  time  to  reduce  the 
heart's  action.  They  may  be  used  alone,  or  in  conjunction  with 
local  treatment.  Space  cannot  be  aff^orded,  in  a  work  on  the 
principles  of  surgery,  for  this  subject,  it  being  strictly  a  medical 
subject.  '' 

Among  the  several  kinds  of  aneurisms  which  were  given  are 
the  varicose,  aneurismal  varix,  and  aneurism  by  anastomosis. ' 

Varicose  aneurism  and  aneurismal  varix  are  spoken  of  to<rether 
m  Holmes's  System  of  Surgery,  under  the  title  of  "  Arterio-Venous 
Aneurism,"  and  with  the  following  definition:  "Under  this  title 
are  mcluded  the  forms  of  aneurismal  dil'  '-ion  of  an  artery  com- 
municating with  a  vein. 

"Varicose   aneurism   consists  of  a  circumscribed  consecutive 
aneunsm,  which  communicates  with  the  artery  on  one  side  and 
the  vein  on  the  other ;  the  vein  is  always  tortuous  and  dilated 
sometmies  to  an  enormous  extent.     Aneurismal  varix  presents  a 
simpler  condition.    Adhesion  has  occurred  between  the  artery  and 
vein  at  the  point  of  communication ;  there  is  no  intervening  aneu- 
nsmal  sac,  and  the  blood  is  projected  directly  from  the  artery  into 
the  vein  at  each  pulsation.     Here  also  the  veins  connected  with 
the  diseased  part  are  greatly  dilated,  and  it  is  owing  to  the  embar- 
rassment of  the  circulation  thus  produced  that  the  injury  com- 
monly becomes  the  cause  of  distress  to  the  patient,  and  claims  the 
care  of  the  surgeon. 

"  Both  of  these  forms  of  arterio-vonous  aneurism  may  originate 
traumatically,  as  the  eff-ect  of  violence,  or  spontaneously,  as  the 
result  of  disease."  -  By  far  the  most  frequent  cause  is  th.  un- 
skilful  performance  of  venesection  at  the  elbow;  but  any  other 
punctured  wound,  the  impact  of  a  small  snot,  injury  from  the 
fragment  of  a  comminuted  fracture,  and,  it  is  said,  even  simple 
contusion,  have  led  to  this  condition." 

Trmtment.-^'<  The  treatment  of  aneurismal  varix  and  varlcoge 


■: 


r     '^JTI 


I 


m 


368 


PRINCIPLES    OP    SURGERY. 


aneurism  must  be  mentioned  separately.  That  of  aneurismal  varix 
presents  great  difficulties.  In  many  cases,  indeed,  the  disease 
manifests  but  little  tendency  to  advance ;  and  where  this  station- 
ary condition  exists,  surgical  interference  may  well  be  omitted." 
In  all  cases,  the  surgeon  should  try  compression,  direct  and  indi- 
rect, in  the  different  ways.  Indirect  pressure  is  the  most  likely  to 
prove  salutary.  Injecting  coagulating  fluid  may  be  cautiously 
tried.  When  all  other  means  fail,  a  ligature  must  be  applied  above 
and  below  the  place  of  communication. 

•  The  treatment  of  the  varicose  aneurism  will  be  essentially  the 
same,  with  this  addition :  the  sac  which  here  exists  must  be  laid 
open,  so  that  the  opening  into  the  artery  can  be  found;  after 
which,  ligature  above  and  below  will  be  applied. 

Aneurism  by  Anastomosis. — This  affection  is  commonly  treated 
of  in  connection  with  aneurisms,  yet,  strictly  speaking,  it  is  a 
tumor,  and  ought  to  be  considered  in  connection  with  other  tu- 
mors. There  is  not  a  morbid  condition  of  the  tissue,  but  rather  a 
morbid  growth  of  the  vessels.  It  is  not  the  arteries  only  that  are 
affected ;  the  capillaries  and  the  veins  may,  instead,  be  the  seat  of 
the  disease.  Such  being  the  case,  the  disease  and  treatment  will 
be  considered  in  the  chapter  on  tumors. 


CHAPTER    XLV. 


Surgical  Aft'ections  of  Veins:    llomnrita.     Plilcbitis:    Symptoms— Treatment. 
Entrance  of  Air  into  Veins :   Symptoms—Treatment. 

Surgical  Affections  of  the  Veins. — This  portion  of  the  vascular 
system  is  liable  to  disease,  as  are  the  arteries.  In  many  respects, 
however,  the  affections  of  the  veins  are  dissimilar  from  those  of 
the  arteries.  This  fact  might  be  expected,  because  the  two  sys- 
tems are  quite  unlike,  both  anatomically  and  physiologically  ;  and 
because  the  blood  circulating  in  the  one  differs  from  that  in  the 
other:  one  being  arterial,  the  other  venous;  and  one  passing  from 
the  heart  in  distinct  waves,  the  other  passing  toward  the  heart  in 
a  more  equable  stream.  There  is  one  peculiarity,  with  respect  to 
the  coats,  that  requires  to  be  noticed.     In  the  artery  is  a  well- 


SURGICAL    AFFECTIONS    OP    THE    VEINS.  369 

developed  elastic  and  muscular  coat,  while  in  the  vein  it  is  far  less 
appreciable.  The  walls  of  the  veins  are  much  thinner ;  and  whl 
the  vessel  is  emptied,  it  at  once  is  collapsed  and  flabby.     Again 

faT  "\T^  "P"^'"^  *^^"  '''''''''     ^"  «f  the  foregoing 
facts  would  lead  us  to  expect  a  dissimilarity  in  the  diseases  pecu 
bar  to  each.     This  is  particularly  so  in  respect  to  inflammation. 
While  chrome  inflammation,  or  a  diseased  action  closely  resem- 

attafkf;!,''  ''  "'^T  '"^  '^'  "'*'"^^'  '^'  inflammation  which 
attacks  the  veins  is  almost  always  acute. 

Acute  Phlebitis  is  a  disease  of  serious  import.  It  is  attended 
with  violent  symptoms,  and  is  often  followed  by  fatal  consequences." 
The  disease  often  aff-ects  a  nur.ber  of  veins  simultaneously,  and  it 
18  said,  always  extends  toward  the  heart 

the^vPif  f  "p'^*''  confounded  with  coagulation  of  blood  within 
he  veins  (see  Pyemia),  which  may  be  a  curative  process,  or  be  due 
to  some  morbid  state  of  the  blood.    When  coagulation  tikes  place, 
V    y  serious  efl-ects  may  follow;  yet  such  is  not  a  necessary  rule 
But  when  true  inflammation  arises  in  the  venous  tissue,  it  consti- 
tu  es  always  a  most  serious  disease.     The  inflammation  is  suppu- 
rative,  and  partakes  much  of  the  character  of  erysipelas.     Indeed 
by  some  it  ,s  ooked  upon  as  a  variety  of  erysipelas.    It  will  gene^ 
ally  be  .ound  that  the  state  of  health  is  much  below  par,  and 
that  upon  the  reception  of  some  injury  involving  the  veins,  gene- 
rally  some  laceration,  the  disease  was  initiated.    The  inflammation 
diffuse,  the  whole  of  the  coats  being  involved,  and  often  the 
tissue  around  also.     Imperfect  clots  of  fibrin  may  form  in  the 
vessel,  and  soon  after  disintegrate.     The  products  ;f  disease  will 

lir  r  T  'T".  "''"'^'^  '^''  "''"'  ''  «^^"™  «"^1  corpuscular 
lymph,  wluch  will  degenerate  into  an  ill-conditioned  pus,  and 
which  will  be  in  small  quantities,  scattered  through  the  part 

S:,mptoms.--Thoy  are,  in  most  respects,  the  same  as  are  seen  in 
phlegmonous  erysipelas.  The  prostration  is  very  great.  The  part 
".  which  the  inflammation  is  located  will  presJnt  an  CBdemafous 
appearance.  The  pain  will  be  principally  along  the  course  of  the 
vessels,  where  Will  also  be  sometimes  a  degree  of  redness 

Treatrnmt.-A.  the  constitution  is  principally  affected,  at  least 

he  vitiated  state  having  been  a  predisposing  cause,  it  will  require 

.mmediato  consideration.     Htimulants  of  the  strongest  kmd  will 

often  be  required,  beef  tea    &,-      T      •  .  / 

I  iiiu,   ucci  tea,  &t.      1.    ,..,  p^rt^  ^arm  fomenta- 

'ii 


-  ; 


i<  ii 


370 


PRINCIPLES    OF    SURaBRY. 


tions ;  and  if  pus  be  collected,  free  incisioiis  must  be  made,  that  it 
may  escape.     (See  Phlegmonous  Erysipelas.) 

Adhesive  Phlebitis. — This  scarcely  requires  a  separate  notice, 
as  it  is  but  a  form  of  the  healing  process. 

Entrance  of  Air  into  wounded  Veins. — Now  and  then  it  hap- 
pens that  during  the  performance  of  a  surgical  operation,  there 
suddenly  is  heard  a  hissing  sound  at  the  place  where  incisions  have 
been  made.  This  sound  is  due  to  the  entrance  of  air  into  a  vein 
whose  coats  have  been  divided.  In  carrying  on  the  operation  the 
cut  in  the  vein  is  by  chance  made  to  open,  whereupon  the  air  rushes 
in,  passes  towards  the  heart,  and  causes  most  alarming  symptoms, 
sometimes  death.  The  explanation  of  this  unfortunate  accident  is 
simple  enough.  It  almost  always  occurs  in  connection  with  wounds 
about  the  neck  or  axilla.  In  order  to  have  the  air  enter  the  vein, 
it  is  necessary  that  at  the  time  the  wound  is  opened  the  patient 
should  inspire.  The  expansion  of  the  chest  in  inspiration  is  al- 
ways attended  with  the  entrance  of  air  through  the  air  passage, 
but  should  another  passage  present  itself,  the  air  will  likewise  en- 
ter by  it.  The  open  vein  affords  another  channel  under  the  fore- 
mentioned  circumstances.  In  the  same  manner  a  wound  into  the 
pleural  sac  will  sometimes  allow  the  air  to  fill  it,  and  thereby 
cause  collapse  of  the  lung. 

Symptoms. — These  are  in  many  respects,  those  of  collapse. 
Sometimes  there  is  only  a  momentary  trembling  or  shudder,  and 
the  patient  is  dead.  Cases  are  recorded  where  the  patient "  expired 
instantly  without  either  sigh,  groan,  or  struggle."  In  all  cases 
the  heart  is  seriously  affected,  beating  irregularly,  often  violently. 
The  breathing  is  embarrassed,  sometimes  sighing.  Sometimes 
there  are  convulsions. 

The  cause  of  these  symptoms  would  seem  to  be  the  presence  of 
air  in  the  right  cavities  of  the  heart.  The  heart  is  designed  alone 
to  pass  along,  and  force  from  it,  a  fluid  substance.  But  here  is  a 
gaH,  upon  which  the  organ  is  impotent  to  act.  The  valves  are  not 
&';ted  upon  by  it,  ami  the  air,  when  the  heart  contracts,  rushes 
back  and  forth,  instead  of  being  propelled  onward.  Sometimes 
the  quantity  of  air  is  so  great  as  to  completely  paralyze  the  heart 
by  over  distension  of  the  auricle.  There  will  soon  bo  formed  a 
frothy  mixture  of  blood  and  air,  which  it  has  been  thought  might 
prevent  its  passage  through  the  capillary  structure  of  the  lung. 


SURGICAL    AFFECTIONS    OF    THE   VEINS.  371 

But  the  causes  of  death  seem  to  be  in  the  heart.    At  least  post- 
mortem  examination  supports  that  view. 

Treatment.-In  the  first  place,  when  operating,  as  in  removal 
ot  a  tumor  about  the  neck,  great  care  should  always  be  taken  not 
to  open  a  vem.  And  when  such  should  unfortunatelv  occur,  to 
see  that  the  orifice  is  not  dilated.  After  the  air  has  entered,  the 
treatment  wil  be  based  upon  the  acknowledged  fact  that  the  air 
cannot  pass  through  the  heart.  Could  the  blood  be  forced  into 
the  right  auricle  the  air  giving  place,  it  would  be  well.  Rubbing 
the  hmbs,  therefore,  towards  the  heart  will  be  advisable,  to  quicken 
the  venous  circulation.  If  the  brain  is  suflFering,  and  syncope  pre- 
sent, the  body  should  be  placed  in  the  recumbent  postu^  Stim  . 
lants  must  be  admmistered,  also  the  galvanic  battery  employed. 

In  those  cases  where  ae  action  of  the  heart  is  overcome,  it  is 
recommended  to  inject  warm  water  into  the  heart.  "  The  nozzle 
of  the  syringe  is  to  be  inserted  into  the  vein  of  the  neck,  and  water 
mjected  toward  the  heart.  The  precautions  and  the'additio  a 
means  are:  1st,  To  raise  the  neck  above  the  level  of  the  heart; 
tha   as  the  water  is  forced  down,  the  air  in  the  heart  may  be  raised 

7  1  .        u    ''?"''  "  ''""  '"  *^'  """^  '^"•i  «^^«"ate  the  blood  in 

t;  that  as  the  air  ascends  during  the  injection,  it  may  find  space 

m  the  higher  veins.     Inject  two  ounces  at  a  time,  with  enough, 

but  not  too  much  force,  carefully,  that  no  air  enters.     Galvanism 

maintained  at  the  same  time."  (C.  H.  Moore,  System  of  Surgery  ) 


::;:  II 


JDT^TQXOJSr    -v. 


MORBID   GROWTHS. 


CHAPTER    XLVI. 


Morbid  Growths:   Division — Analogous — Heterologous — Fibrous.     Diagno- 
sis —  Treatment  —  Fibroid  —  Fatty  —  Cartilaginous  —  Myeloid  —  Osseous 

Three  Kinds  —  Exostosis — Osteophyte — Osteoid — Cystoid  —  Glandular- 
Vascular — Sarcomatous. 


Morbid  Growths — Tumors. — Although  morbid  growths  and  tu- 
mors are  placed  as  if  synonymous,  it  may  not  be  generally  admit- 
ted that  there  is  a  necessary  connection  between  them. 

In  the  first  place  let  us  endeavor  to  have  a  distinct  understand- 
ing as  to  the  meaning  of  morbid  growths.  In  the  first  chapter,  on 
nutrition,  the  subject  of  natural  growth  is  alluded  to.  But  what 
is  meant  by  unnatural  or  morbid  growth  ?  I  am  disposed  to  adopt 
the  views  of  Virchow  in  this  respect,  and  to  regard  unnatural 
growth  or  new  formations  simply  as  a  deviation  from  the  normal 
growth.  He  says,  "  We  may,  therefore,  with  trifling  restrictions, 
substitute  for  the  plastic  lymph  the  blastema  of  the  earlier,  the  exu- 
dation of  the  later  writers,  connective  tissue  with  its  equivalents  as 
the  common  stock  of  germs  of  the  body,  and  directly  trace  to  it  as 
the  general  source  of  the  development  of  new  formations." 

A  tumor,  in  its  broadest  signification,  includes  a  variety  of  mor- 
bid operations.  In  one  sense,  all  tumors  are  morbid  growths.  To 
elucidate  the  principles  it  will  be  preferable  to  classify  tumors, 
give  the  cause  of  each  kind,  and  at  the  same  time,  point  out  the 
difference  between  them. 

Division  of  Tumors. — First,  they  may  bo  divided  into  analogous 
and  heterologous.  The  ordinary  interpreta^on  of  these  terms  is, 
that  the  analogous  tumor  is  one  vvho.><j  structure  bears  a  likeness 
to  some  tissue  of  the  body,  although  it  may  be  unlike  the  tissue  in 
which  it  has  grown,  and  from  which  it  derives  its  strength.   Jletero- 


MORBID    GROWTHS. 


373 


logom  has  been  applied  to  such  tumors  as  have  nothing  in  commcn 
with  any  natural  structure  of  the  body;  this,  at  least,  is  what  the 
name  implies.     An  analogous  tumor  has  generally  been  regarded 
as  a  benignant  one,  and  the  heterologous  tumor  as  malignant, 
the  type  of  which  is  cancer.     But  these  long-recognized  views 
cannot  be  regarded  as  strictly  correct.     Indeed,  if  we  adopt  the 
views  of  Virchow,  we  cannot  regard  every  growth  as  an  offspring 
of  natural  tissue ;  and  who  can  say  positively  where  the  natural 
verges  into  the  unnatural  ?     Lmus  naturcB  of  various  kinds,  mon- 
strosities,  malformations,  superfluities  of  parts,  &c.,  are  every  day 
to  be  seen,  both  in  the  animal  and  vegetable  world,  and  so  it  is  in 
the  human  organism,  although  in  a  less  appreciable  degree  ;  built 
up  of  innumerable  single  cells,  which  have  been  in  the  order  of 
nature  created  and  developed,  and  which,  having   begotten  off- 
spring,  ultimately  die.     The  body  is  made  up  of  these  independent 
lives,  each  of  which  performs  its  circle  of  duty,  and  then  passes 
away,  being  succeeded  by  other  similar  creations.     But,  as  the 
child  may  in  one  or  in  many  respects  be  unlike  the  father,  so  these 
cells  may  to  a  greater  or  less  extent  be  dissimilar  from  their  pa- 
rents.    It  IS  when  the  young  cell  deviates  from  the  character  of 
the  parent  cell  that  heterology  may  be  said  to  have  commenced. 
(Virchow.)     This  has  more  commonly  been  regarded  as  a  trans- 
formation  of  tissue.     And  very  often  the  change  in  the  individual 
cells  IS  that  from  one  kind  into  another  natural  kind.     But  when 
the  change  is  into  structure  unlike  any  tissue  in  the  natural  body 
It  may  not  be  regarded  as  a  transformation. 

The  new  formation  may  be  limited  to  a  few  cells,  or  a  circum- 
scribed  part;  or  a  more  extensive  district  may  be  changed     or 
even  a  whole  organ,  or  muscle,  or  other  individual  tissue,  may 
have  departed  from  a  state  of  nature.     Attending  this  change 
there  may  be  no  deviation  from  the  natural  dimemionB;  or,  on 
iU  contrary,  there  may  bo  hypertrophy,  or  there  may  be  atrophy 
liut  more  generally,  in  connection  with  a  transformation,  there 
will  bo  an  addition,  and  consequently  an  hypertrophy.     When  an 
organ  or  tissue  is  no  longer  used,  the  structi:.-^  will  become  both 
transformed  and  decreased  in  volume.    Ar..'  when  the  hypertrophy 
IB  Umited  to  a  circumscribed  spot,  so  as  to  cause  an  unusual  promt- 
nencc,  the  term  tumor  may  be  properly  applied. 

Speaking  broadly,  then,  a  morbid  growth  is  a  deviaf.V 


^!il 


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Lrinn_  m/\>.<> 


874 


PRINCIPLES    OF    SURGERY. 


or  less  great,  from  natural  repair  of  tissue  (nutrition).  Instead  of 
only  a  repetition  of  tissue,  which  has,  in  the  order  of  nature,  per- 
ished, there  is  an  increase.  This  increase  may  be  in  accordance 
with  physiological  laws  (natural  growth),  or  it  may  be  a  wild  and 
wayward  shoot — a  fungus. 

In  the  consideration  of  tumors,  this  principle  will  be  found  to 
be  ever  applicable,  although  in  many  cases  much  modified. 

Tumors,  again,  may  be  divided  according  to  the  nature  of  the 
morbid  structure ;  first,  into  those  which  are  solid,  and  those  con- 
taining fluid.  A  more  practical  division  is  one  based  upon  the 
actual  constituents  of  the  mass,  their  appearance,  and  their  con- 
sistence. Space  cannot  be  given  to  a  complete  discussion  of  all 
kinds  of  tumors ;  but  attention,  at  least,  will  be  given  to  such  as 
ar«  of  the  most  importance  to  surgeons.  The  following  varieties 
will  be  considered :  fibrous,  fibroid,  epidermic,  fatty,  cartilaginous, 
osseous,  myeloid,  cystoid,  glandular,  vascular,  cancerous. 

Fibrous. — This  form  may  appropriately  be  considered  first,  as 
it  is  a  very  common  kind.  Indeed,  the  fibrous  element  is  found  in 
almost  every  kind  of  tumor.  A  fibrous  tumor  is  generally  dis- 
tinctly marked,  and  is  separated  from  the  tissue  in  which  it  is 
imbedded  by  a  well-marked  division.  The  origin  of  the  fibrous 
tumor  is  not  always  discoverable.  Perhaps  the  more  frequent 
cause  is  some  injury,  in  consequence  of  which  a  small  quantity  of 
fibrin  is  deposited,  and  which  gradually  undergoes  development. 
The  tumor  is  never  very  well  supplied  with  bloodvessels,  and  its 
growth  is  slow. 

The  Form. — It  may  present  a  variety  of  shapes,  the  form  being 
moulded  by  the  degree  of  firmness  in  the  tissues  around.  It  may 
be  round  or  oval,  or  pyriform,  or  in  the  form  of  a  polypus  The 
consistence  is  not  always  the  same ;  this  will  depend  upon  the 
amount  of  fibrous  element  actually  composing  the  tumor.  Some- 
times the  tumor  will  be  made  up  of  several  smaller  ones,  which, 
in  growing,  had  coalesced  and  become  incorporated.  The  whole 
will  present  a  lobulated  appearance. 

Internal  Appearance. — When  a  fibrous  tumor  is  divided  by  the 
knife,  it  is  generally  found  to  present  a  whitish  appearance,  with 
the  fibres  in  bundles  traversing  the  mass.  These  fibres  sometimes 
present  a  concentric  form.    Examined  by  the  microscope,  they  are 


MORBID    GROWTHS. 


375 


found  to  resemble  closely  those  of  normal  tissue.     Among  the 
fibres  will  be  seen  a  few  elongated  cells. 


s   >,-,<  I 


Sabitat.-The  parts  of  the  body  in  which  this  tumor  is  most 
frequently  met  are  the  nose,  pharynx,  uterus,  the  nerves,  the 
bones,  and  near  the  joints;  yet  they  are  often  seen  in  other 
parts. 

Size.—It  may  attain  to  a  very  large  size.  Being  of  slow 
growth,  It  may,— as,  for  instance,  in  the  terus,  where  it  can  be 
accommodated  by  the  yielding  tissue,-become  of  immense  size, 
and  yet  the  constitution  bo  but  little  affected.  In  time,  however, 
by  Its  weight  and  presence,  it  will  lead  to  death. 

Diagnosis.— The  surgeon  will  notice  the  locality,  the  shape,  the 
density,  the  fact  that  it  is  slow  of  growth,  without  pain  while 
growing.  Excepting  when  it  is  located  in  bone,  attention  to  the 
above  points  will  enable  him  to  distinguish  the  fibrous  tumor  from 
enlarged  glands,  from  cysts  with  thioh  xv«^u  f^^^i  «i>~".-'J -l- 


376 


PRINCIPLES    OP    SUKGERY. 


■ 


from  cancerous  formations ;  all  of  which  are  the  tumors  to  which 
the  fibrous  sometimes  bears  some  resemblance. 

Treatment. — "  In  the  treatment  of  fibrous  tumors  (not  including 
those  of  the  uterus),  excision  is  the  only  available  remedy,  and 
had  better  be  resorted  to  without  delay.  The  method  must  vary 
according  to  the  seat  of  the  tumor.  Simple  enucleation  is  rarely 
possible  in  those  within  the  nerves,  bones,  or  lobules  of  the  ears, 
though  in  the  first  two  it  may  be  very  often  worth  attempting." 
(System  of  Surgery.) 

Fibroid  Tumor. — This  tumor  was  first  thus  called  by  Paget.  It 
closely  resembles,  in  appearance  and  consistence,  the  fibrous.  But 
in  behavior  it  is  quite  unlike  the  fibrous.  The  latter,  when  re- 
moved, rarely  returns,  being  essentially  a  local  disease,  so  that 
when  it  is  extirpated  the  whole  system  is  freed ;  but  the  fibroid 
manifests  a  decided  tendency  to  return,  and  sometimes  in  increased 
numbers.  From  this  pathological  fact,  it  would  seem  that  the 
constitution  had  originally  been  impregnated  with  a  morbid  ele- 
ment, or  that  the  local  growth  had  before  its  removal  imparted  to 
the  constitution  the  fatal  power  to  reproduce  the  unnatural 
growth. 

The  microscope  discovers  numerous  cells  in  the  fibroid  mass, 
which  bear  a  closer  resemblance  to  those  of  cancer  than  to  those 

which  are  seen  in  the  fibrous 
tumor.  Moreover,  every  succes- 
sively recurring  growth  manifests 
a  more  malignant  behavior  than 
its  predecessor.  Hence,  this 
^=3=^  vp^—  formation  has  been  regarded  by 

^     \  pathologists  as  a  connecting  link 

between  the  class  of  innocent 
and  that  of  malignant  tumors.  As  might  be  expected  from  the 
existence  of  the  more  numerous  and  the  caudate  cell,  the  tumor 
has  a  more  generous  supply  of  bloodvessels,  and  the  growth  of  the 
tumor  is  consequently  more  rapid. 

Diagnosis. — When  the  primary  tumor  exists,  it  will  be  impossi- 
ble to  say  that  it  does  or  does  not  belong  to  the  fibroid  class.  A 
tumor  with  the  outside  indications  of  a  fibrous  growth,  but  which 
grows  rapidly,  will  always  be  regarded  with  suspicion,  and  as  one 
likely  to  recur.     Subsequently,  the  microscopical  appearance  of 


MORBID    GROWTHS. 


877 


the  primary  tumor,  and  the  reappearance,  will  bear  convincinir 
testimony  as  to  its  character. 

Treatment-Yevj  often,  the  patient  seeks  to  have  a  tumor  re- 
moved  only  on  the  assurance  of  the  surgeon  that  it  will  not  return. 
Jiut  m  no  case  should  he  positively  declare  that  a  growth  will  not 
return.  And  when  its  growth  has  been  rapid,  there  will  be  the 
greater  caution  necessary.  In  performing  the  operation,  care 
should  be  taken  to  completely  extirpate  all  of  the  morbid  tissue 
around  the  more  perceptible  morbid  mass.  In  every  case,  notice 
must  be  taken  whether  there  be  anything  which  mav,  by  causing 
irritation,  tend  to  promote  the  growth,  and,  when  p;ssible,  to  re- 
move all  such.  Sometimes  pressure,  judiciously  applied,  may  to 
some  extent  retard  the  growth. 

Epidermic  Tumor,  or  UpitheUaL-Evevj  day,  examples  of  this 
class  may  be  seen,  in  the  form  of  warts,  corns,  &c.     The  growth 
IS  morbid  in  this  respect.     The  layers  of  epithelial  scales  gradu- 
ally accumulate  in  a  circumscribed  space,  until  the  thickening 
assumes  *he  form  of  a  tumor,  or  vegetable-like  growth.     A  com- 
mon situation  for  them  is  at  the  anus,  and  opening  of  the  vagina 
caused  by  irritating  discharge.     They  may  be  isolated;  or  clus' 
tered  together;  sometimes  actually  coalesced,  and  bearing  resem- 
blance  to  the  cauliflower  excrescence  peculiar  to  epithelial  cancer 
Diagnosis.-It  may  be  mistaken  for  an  epithelial  cancer.     Epi- 
thelial cancer  may  appear  about  the  genitals,  but  is  more  commonly 
m  the  form  of  chimney-sweep's  cancer.     In  other  places,  also 
both  malignant  and  non-malignant  epithelial  growths  may  form' 
lor  the  distinguishing  marks  of  cancer,  see  that  disease. 

Treatment— Comphte  excision  is  the  only  remedy;  and  gene- 
rally, there  will  be  no  return.     Caustics  may  be  used  instead,  to 
procure  removal.     Cleanliness  will,  as  a  general  thing,  prevent 
their  formation.     Respecting  corns, -epithelial  growths  upon  or 
about  the  toes,  and  which  are  generally  due  to  the  pressure  of  ill- 
made  or  tightly-fitting  boots,  in  connection  with  the  irritating 
perspiration  of  the  part,— I  have  space  only  to  make  a  few  re- 
marks.    The  first  and  essential  thing  is  to  remove  the  cause      If 
pressure  bo  quite  prevented,  in  most  cases  the  corn  will  cease  to 
grow  and  entirely  disappear.    Paring  may  be  practised  to  advan- 
tage, being  careful  not  to  cut  so  deep  as  to  wound.     I  have  found 
friction,  to  a  great  extent,  to  be  obviated  by  the  daily  application 


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PRINCIPLES    OF    SDROBRT. 


of  a  little  sweet  oil,  with  daily  ablution.  Sometimes  the  corn  is 
exceedingly  painful,  either  from  it  being  inflamed  at  its  base,  or 
from  the  presence  of  a  nerve  in  immediate  contact  with  the  corn. 
In  the  former  case,  cooling  and  astringent  lotions  will  be  required. 
Sometimes  a  drop  or  two  of  pus  will  form ;  if  so,  it  must  be  let 
out.  In  the  latter  case,  I  have  often  found  the  application  of 
nitrate  of  silver  stick  have  the  effect  of  permanently  removing 
the  pain.  Should  the  pain,  however,  remain,  it  may  be  necessary 
to  divide  the  nerve-trunk  a  short  distance  from  the  tumor. 

Fatty  Tumor,  or  Lipomata. — This  tumor  is  not  of  unfrequent 
occurrence.  Whether  examined  by  the  naked  eye  or  the  micro- 
scope, the  fatty  tumor  exactly  resembles  normal  fat.  The  cells 
are  quite  alike,  and  the  chemical  constituents  in  both  cases  con- 
sist of  oleine  and  margarine.  Sometimes,  however,  the  latter  is  in 
excess.  Entering  into  the  formation  of  the  tumor,  there  may  be 
more  or  less  of  fibrous  tissue.  The  greater  the  quantity,  the 
more  firm  will  be  the  tumor.  Fatty  tumors  may  form  in  any  part 
of  the  body,  but  are  more  frequently  seen  where  fat  naturally 
exists — as  in  the  back,  neck,  and  thighs.  Several  may  coexist, 
but  more  often  there  is  but  one.  It  sometimes  grows  to  a  very 
large  size :  even  to  sixty  pounds,  it  is  recorded.  The  tumor  is 
commonly  surrounded  by  a  cyst. 

Diagnosi%. — The  growth  is  mostly  always  slow,  and  it  is  cha- 
racterized by  a  doughy  sensation  to  the  fingers.  It  must  be 
remembered  that  certain  regions  of  the  body  are  more  likely  to  be 
the  seat  of  its  formation.  The  tumor  sometimes  changes  from  one 
site  to  another,  owing  to  the  lax  nature  of  the  capsule  around. 
Thus,  it  may  gradually  gravitate  from  the  groin  to  the  thigh,  or 
from  the  perineum  to  the  scrotum.     (Paget.) 

Treatment. — Excision  ought,  as  a  general  thing,  to  be  resorted 
to  without  delay.  If  a  number  exist,  it  may  not  be  possible  to 
remove  all ;  but  the  one  most  obnoxious  may  be  removed.  If 
not  removed,  and  growth  continue,  the  pressure  upon  the  adjacent 
tissue,  or  the  great  weight,  may  lead  to  exhaustion  and  death  of 
the  patient. 

Cartilaginous  Tumor,  or  Enchondromata. — The  following  ac- 
count is  principally  derived  from  Paget's  System  of  Surgery. 

While  this  tumor  is  most  frequently  met  with  in  connection 
with  bone,  it  is  now  and  then  met  with  in  the  parotid  gland  and 


MORBID    GROWTHS. 


379 


the  testicles.  By  far  the  mosu  common  site  is  on  the  phalanges 
and  the  metacarpal  hones.  It  presents  an  irregular  or  nodulated 
appearance.     To  the  touch,  it  is  hard  and  resisting,  as  a  general 


thing.     When  cut  into,  the  tumor  will  seem  as  if  composed  of 
several  tumors  bound  together  by  connective  tissue.     The  whole 
is  of  a  bluish  white  and  glistening  appearance.     In  most  respects 
the  substance  resembles,  both  to  the  eye  and  with  the  microscope 
the  foetal  cartilage.    In 
the  tumor,  ossification 
"  may  here  and  there  be 
taking  place;   or,    ou 
the     contrary,     there 
may  be  some  points  of 

softening.     The  whole  j<  p^ 

tumor  occasionally  be-  ^         ^         L,         vS 

comes  bone.     The  sof- 
tening may  be  duo  to  degeneration,  and  there  may  be  several 
cavities  filled  with  fluid. 

Caum.— These  are  sometimes  hereditary.     Now  and  then  it  is 

due  to  an  injury.    It  may  arise  from  the  exterior  or  from  the  into- 

nor  of  a  bono,  and  often  begins  in  early  life.    The  growth  is  always 

slow,  and  attended  with  no  pain.    The  cartilaginous  tum^r  is  often 

mixed.  '     "  Thus,  nodules  of  cartilage  are  not  very  rare  in  fibro- 

cellular  tumors;  tho  nartila^Jno"-  ♦•• ■ -•  -3 

-!  --i-  _«^  i...ag.„.;^j,  vuiiivjB  111  vr  licar  sne  parotid 


380 


PRINCIPLES    OP    SURGERY. 


gland  have  commonly  an  intermixture  of  glandular  tissue ;  many 
of  those  in  bones  are  mixed  with  myeloid  structure,  and  in  the 
testicle,  cartilage  and  medullary  cancer  have  often  occurred  in  an 
apparently  single  tumor."  (System  of  Surgery.) 

Diagnosia.— Its  situation,  extreme  hardness,  its  lobulated  ap- 
pearance—all will  assist  the  surgeon  to  arrive  at  a  correct  decision. 
It  may  be  mistaken  for  scirrhus,  or  a  lymph-gland  filled  with 
calcareous  matter.  But  scirrhus  is  not  an  inhabitant  of  the  same 
part  of  the  body  as  the  cartilaginous.  And  glands  with  calcare- 
ous matter  do  not  regularly  grow  like  the  cartilaginous. 

Treatment— RemovaX  is  the  only  remedy.  This  is  sometimes 
difficult  from  the  capsule  being  firmly  adherent  to  the  surrounding 
parts.  In  the  parotid  region  the  lobules  may  dip  down  into  the 
deeper  regions,  and  even  surround  important  vessels  and  nerves 
rendering  the  removal  extremely  difficult,  perhaps  impossible! 
When  such  a  condition  is  unfortunately  met  with,  a  portion  "may 
be  left,  with  a  good  probability  that  it  will  not  increase."  As  a 
general  thing,  when  removed  there  is  no  recurrence. 

''Myeloid  Tumors  are  distinguished  by   their   containing  or 
being  chiefly  composed  of  minute  structures,  similar  to  those  of 
foetal  marrow  or  diploe."     "  The  myeloid  tumors  affect  especially 
the  bones,  and  it  is  not  yet  certain  that  they  ever  occur  as  pri- 
mary  growths  in  any  other  structure,  though  tumors  much  like 
them  have  been  found  in  the  breast  and  other  parts."     "Like 
the  fibrous  and  cartilaginous,  a  myeloid  tumor  may  grow  either 
within  a  bone  or  on  the  surface  of  one;  unlike  them,  it  is  more 
frequently  found  as  an  interior  growth."     "  When  not  encased  in 
bone,  they  usually  feel  firm.     Compressible,  slowly  resilient  and 
'fleshy;'  very  few  are  harder  than  these  words  imply,  but  some 
•re  much    softer,   easily  broken,   like   ordinary  granulations." 
They  may  widely  vary  in  appeaiance  and  consistence.     In  the 
interior  of  the  mass  may  be  one  or  more  cysts,  containing  various 
fluids.     "  The  most  distinctive  microscopic  structures  of  myeloid 
tumors  are  many-nuclealed  bodies,  cells,  or  masses,  or  disks,  re- 
sembling cells.     Of  these,  the  greater  part  are  oval  or  roundish"— 
"  their  nuclei,  from  two  to  ten  or  more  in  number,  are  oval,  small, 
well  defined,  nucleolated." 

Cau«e«.— There  is  no  cause  which  is  common.    Thoy  ordinarily 
grow  at  mature  life.     Their  growth  is  slow  and  without  irritation. 


MORBID    GROWTHS. 


381 


«v«frfiK      •"■  ^^'/'^''''^  ™^^*  ^^'^y  ''  ^e  confounded  are 
cysts,  fibrous  or  cartilaginous  tumors,  and  cancer  of  bones  "     It 

will  no    be  forgotten  that  the  myeloid  tumor  is  more  frelentlv 

p,:r  '"  '"  "^''^  ""'^P^^'^  '^'  «^«^«  -«  for  the  fibrous 

Recurrence  is  very  uncommon.  norous. 

0.«..u.  ^t.^...._The  division  of  osseous  tumors,  as  given  by 
Jones  and  Sieveking,  will  probably  be  found  the  most  p  acticaf 
VIZ.,  exostosis,  osteophytes,  osteoid.  Practical, 

I!xostosis.--ms  proceeds  from  the  bone  or  its  periosteum  The 
form  vanes  ;  it  may  be  broad  and  flat,  or  round'and  prominent 

ThereVT\  "''''  ''  "^^  ^**^^"  '^  *^«  «-  of  ^  hen  egg' 
There  may  be  but  one  or  there  may  be  several  in  the  same  bonf 
or  m  different  parts  of  the  osseous  structure.  ' 

The  density   varies;    some- 
times it  is  very  hard,  constituting 
i  vory  exostosis,  or  it  may  be  soft, 
cancellous,  forming  the  spongy 
exostosis.     The  ivory  form  is 
more    prominent— more    d«^ci- 
dedly  a  tumor,  while  the  soft 
is  often  merely  a  circumscribed 
expansion  of  the  bone.     Some- 
times the  growth  is  in  the  me- 
dullary canal,  when  it  is  called 
an  exostosis. 

t'aMse.— This  is  often  a  blow, 
or  some  other  injury. 

Osteophjte.—ThiB  differs  from 
the  preceding,  in  that  it  is  easily 
separated  from  the  bone,  from 

which  it  has  grown.     It  is  more  properly  a  tumor.     The  osseous 
formation  is  independent  of  the  bone,  except  that  it  grows  unde 
Its  influence.     It  may  be  found  in  connection  with  diLsed  bone 
and  may  often  be  attributed  to  the  disease,  or  rather  th    effZ 

:  ict  :r::tT  'r  '"^^^ "  '™^  ^^'^'  *^  ^^^^  ^^^  ^--tb 

Which  will  not  have  been  properly  supplied. 

Osteoid  Tumcr^.^Rokitansky  regards  these   as  cancerous  in 


Mi, 

0: 


:,Al  ,  I 


l\ 


fii 


I 


382 


PRINCIPLES    OP    SURGERY. 


their  nature,  being  a  cancerous  growth  with  an  ossific  base.  The 
tumor  may  be  regarded  as  one  which  partakes  of  both  the  bony 
and  fibrous  formation. 

Biagnom.— It  will  be  exceedingly  difficult  at  times  to  distin- 
guish the  osteoid  tumor  from  a  true  cancer  of  the  bone.  Indeed, 
it  would  almost  seem  that  a  distinct  line  of  demarcation  cannot  be 
drawn  between  them. 

Treatment  of  Bony  Orowths.—"'  In  the  treatment  of  these  hard 
osseous  tumors,  excision  is  the  only  fit  remedy  for  those  on  the 
vault  of  the  skull.  But  it  should  not  be  undertaken  unless  it  is 
certain  that  the  tumor  is  increasing,  or  for  some  equally  good  rea- 
son, for  the  extreme  hardness  of  the  bone  makes  the  operation 
difficult,  and  not  a  little  dangerous,"  "Occasional  cures  of 
such  tumors  by  necrosis  and  spontaneous  separation  may  justify, 
in  some  instances,  the  practice  of  exposing  their  most  prominent 


part,  and  destroying  it  with  some  caustic,  in  the  hope  of  killing 
the  whole  mass,  so  that  it  may  exfoliate." 

"  There  is  no  probability  of  renewal  of  growth  after  the  removal 
of  an  osseous  tumor,  and  even  when  the  base  of  the  attachment  is 
left,  it  is  not  likely  to  grow  again." 

CyBtoid  Tumor8.—T\\\%  is  one  of  the  most  important  classes. 
Indeed,  Paget,  in  his  System  of  Surgery,  divides  all  innocent  tu- 


MORBID    GROWTHS. 


383 


mors  into  cysts  and  solid  tumors,  and  among  the  former  he  has  a 

-^arge  number,  viz.,  ,erom,  synovial,  mucom,  sanguineous,  oily, 

.  colloid,  seminal,  &c.  ^' 

Speaking  generally,  cystic  tumors  are  composed  of  two  parts, 
the  cyst  and  the  contents  of  the  cyst.     The  nature  of  the  contents 
varies  much,  and  it  is  this 
variety    which    gives    the 
several  names  above  men- 
tioned.    The   contents   do 
not  always  remain  the  same ; 
indeed,  as  a  general  thing, 
they  undergo    changes   in 
consistence   and   in    color. 
When    the  fluid  is  serum- 
like,  the  tumor  is  called  se- 
rous; and  when  it  resem- 
bles mucus,  it  is  known  as  a  mucous  cyst,  &c.     Cysts  are  called 


compound  or  proliferous  when  two  or  more  are  found  coexisting. 
These  multiple  growths  may  all  be  primary,  but  more  often  thev 


I 


884 


PRINCIPLES    OF    SUBGERY. 


are  found  as  parent  and  offspring.  Such  are  properly  proliferous 
cysts.  They  are  particularly  seen  as  morbid  growths  of  Graafian 
vesicles  of  the  ovaries.  However  interesting  these  may  be  to 
pathologists  and  even  to  surgeons,  it  is  not  possible  to  dilate  upon 
their  nature  here. 

Paget  particularly  describes  proliferous  cysts  with  vascular 
growth,  which  "  are  most  frequently  found  in  or  near  glands, 
especially  the  mammary,  labial,  thyroid,  and  prostate  glands."  He 
says  the  walls  are  formed  of  thin  connective  tissue,  smoothly 
lined  within,  and  externally  closely  adherent  to  the  surrounding 
parts.  .The  cyst  may  contain  any  kind  of  fluid  until  the  peculiar 
growth  occupies  its  cavity  instead.  This  vascular  growth  com- 
mences  from  points  which  gradually  extend  until  the  whole  cavity 
is  filled.  Continuing  to  grow,  the  cyst  is  gradually  distended  till 
it  is  destroyed,  and  the  mass  presents  an  appearance  much  like  the 
excrescence  of  a  cancer.     The  consistence  and  color  vary  much. 

Diagnoais.— It  is  important  to  distinguish  it  from  cancer.  The 
absence  of  symptoms  peculiar  to  cancer,  and  the  healthy  state  of 
the  parts  immediately  around  the  cyst,  as  well  as  of  the  constitu- 
tion generally,  will  enable  the  surgeon  in  most  cases  to  render  a 
correct  diagnosis. 

Cause.— With  regard  to  cysts  generally,  which  we  have  seen 
may  contain  one  of  a  variety  of  fluids,  there  are  several  ways  in 
which  they  may  form.     A  normal  cell,  as  in  the  ovary,  may  be 
gradually  distended  until  a  tumor  is  formed.     Again,  a  duct  of  a 
sebaceous  or  a  mucous  follicle  may  become  obstructed,  and  the  na- 
tural secretion,  gradually  increasing  and  becoming  changed,  may 
so  dilate  the  duct  that  a  cyst  will  result.     Then  a  cyst  may  arise 
from  a  collection  of  fluid  in  the  cellular  tissue ;  many  of  the  cell- 
walls  break  down,  forming  a  space  into  which  fluid  will  collect, 
and  gradually  press  and  condense  the  cellular  tissue  around.    Ulti- 
mately it  becomes  organized  into  a  sac,  in  a  manner  resembling 
the  formation  of  a  bursse  under  friction.     Sometimes  the  cyst  is 
composed  of  connective   tissue,  as  in  certain  cutaneous   cysts. 
These  may  also  be  in  deep-seated  organs  as  well  as  in  the  skin. 
They  may  be  congenital.     The  type  of  this  form  is  found  in  the 
ovaries  in  connection  with  tumors  containing  what  is  natural  upon 
skin,  as  hairs  and  hair  follicles. 

Treatment.— I  shall  speak  only  of  those  upon  the  surface  of  the 


MORBID    GROWTHS. 


885 


the  cyst  may  unite  bv  2(,i  .  hereupon  the  walls  of 

i'  may  by 'a  small  pi:  t;  I^:  ^      b^^  "•'"'•'  r'"''^' 
certain  method  of  treatmlr  ! T    u  '""™  "  ""  ■»"»' 

adopted.     Unless  thlr'Tf'  I      "''"'  P™'""''''^  »ho„ld  be 

ing  tissue,  Xl^yZlZ'mZ  ^-T'  '"  '"'  ^"™»"''- 

bo  .0  difliouuy  e.peLe:dtt:^o^z;ir':::tirr'' 

not  necessary  to  ejcise  the  cyst  entire  oi,  T  '^-  ^'  '» 
opening  it  and  allowing  the  contents  toln  ..'  '""'*""^'  "'^ 
easily  detached  from  it's  bed  and  Ita Xd  T'is  ^f  ^^  "^ 
the  whole  of  the  cyst  lest  f™™  °''™""«''-    "  's  well  to  remove 

the  growth  shonl/t'::  r  "I  ZeV:;'  17"°"  "'"^'■""«' 
after  removal  is  desirable  t„  „™  i  .    t     ,    '"A^raMory  action 

-0  union  should  no  bsou;hf:t;^^^^^  "'  *»  «^"' 

the  surgeon.  T„  secure  /eslruct  Te  e"^  ttT^  ""^'  "^ 
sometimes  necessary  to  apply  the  nilr»t.  ?f  ^^r     /  °  "^"  "  '» 

aiandular  Tumor -ByliTJ  '^"^  "^'^  ■■™»™'- 

growths  arising  from  ,ui:^;  stlrsTto^hT' ^  t  iT" 
some  resemblance  to  gfandular  tissue     Not      ,  "'""''' ''''"' 

!.re  formed  by  enlarged  rfands  »  ,'  ^  "''"^1''™%.  '"-ors 
of  a  larger  Jand  Z\t:^.;i  'SS?  t '  "'  '^^-f  ^ 
structure  li.e  that  of  a  gland,  ^U.  hetunrrSly  to' 

sormr::-^fp:^;^;:::i:^f,rn%'^^^^^  '=- ''  -^ 

and  the  applicatfon  of  th'etct 'rodt     "1^!™?  '°™' 
the  tincture  of  iron,  alone  an^  Jn  „     •  ^^®  ''^^^  ^^^^^ 

tum'o?r::;  dt^i^.^i'^rV"" "»-»'-  *« 

necessary  to  senar!  e  tf^     ..      '^''-    ^"""'^^We  care  will  be 

-hich  arc  of  comin  Jl  U  The' mtTd"'  "'"l'  °'  '""'"^• 

of  normal  vascular  tissue,  T  Chief  irbt  /"""';  "  """'^  "^ 

The  blood  in  the  tumor  ;ill  notalwavs  ,  1  '"';°'''""  '■''"''^• 

q»antity,  and  consequently  i tsXe  wm^l    ,  .'"  "'"  '"""' 

but  will  from  time  to  time  vay     The  bloM        7'  ""  ""'  '"""' 

e  vary,    ine  bloodvessels  are  enlarged  in 

9/1 


i.  ; 


li 


;<& 


386 


PRINCIPLES    OF    SURGERY. 


size ;  their  calibre  is  increased ;  their  number  greater.  They  may 
resemble  the  arterial,  or  the  venous,  or  the  capillary  vessels ;  and 
the  blood  occupying  the  tumor  may  be  arterial  or  venous.     When 


the  structure  is  filled  with  venous  blood,  the  tumor  presents  a 
bluish  appearance ;  when  it  is  arterial  blood,  the  tumor  is  reddish, 
and  constitutes  aneurism  by  anastomosis.    These  growths  are  most 
frequently  seen  in  the  skin  or  subcutaneous  tissue;  they  may, 
however,  exist  in  deep-seated  structures.     They  may  come  after 
birth,  but  are  more  generally  congenital.    Of  a  large  number  that 
have  come  under  my  care  and  notice,  I  never  saw  one  not  conge- 
nital.    They  commonly  go  by  the  term  naevus,  or  mother's  mark, 
from  the  belief  that  certain  impressions  on  the  mother  during 
pregnancy  were  fixed  upon  some  part  of  the  child  in  the  womb. 
At  birth  it  may  be  very  small ;  but  in  a  few  weeks,  or  months, 
perhaps  a  longer  time,— in  consequence,  seemingly,  of  the  larger 
quantity  of  arterial  blood  circulating  therein, — its  growth  will  be 
found  far  in  excess  of  other  structures  of  the  body.     The  face 
and  head  are  the  situations  more  commonly  the  seat  of  vascular 
tumors.     When  venous,  and  presenting  a  dark-blue  appearance, 
it  is  sometimes  looked  upon  by  the  non-professional  as  a  cancerous 
formation. 

Diagnosis. — The  educated  surgeon,  of  any  experience,  is  not 
likely  to  be  at  a  loss  to  recognize  a  vascular  tumor.  The  appear- 
ance and  the  history  of  the  case  are  generally  fully  sufficient  to 
indicate  its  character. 

Treatment. — Being  unsightly,  the  surgeon  is  generally  sought 
to  treat  it ;  but  sometimes  the  superstitious  will  hesitate  to  have 
anything  done  with  a  "Providential  thing."     If  the  tumor  does 


MORBID    GROWTHS. 


387 


00/ 

duo.  oonaolidaTo"  '.h^  reZT""™'-'  °'  '™'  '»  P™" 
whioh  „ay  be  produced  by  a  ™  L"  v  'of  ^  °"T«  '-a™"""-", 
potential  or  the  actual  cautiy  Tv^-  /"^'j  ""y  ""^  "»«  »'  «■« 
tumor  is  su,all  i„  circumfeS;  !LTv  T-'  '^  T™"-  »  «« 
M  «  bone,  a  cure  is  auit,-  IT  u  f  """'^'og  «  Wd  structure, 
ing  the  ir'ou  is  ghlfr  corr„ td  {  '^'^f  •'™'™^=-  ^'J-'- 
is  followed  by  a  great  deriono.  ,  ^r^'  *'"'  '°"'''''»^»  "»>,,» 
flammatory  action  ^.hinbi/d  '""r"""'""-     However,  in- 

cure.  There  are  a  r  °  Jf  t-""'  ^'<-'"'"'"  ""'  ^"^'"^  "' 
induced.  Vaccination  L;t.h''jt  ^b'T™'"""  "^^  "' 
introduction  of  a  seton  throuA  T  7  '  ""  ''^""  »"«  «  the 
first  place,  destroystporS  h!  '    <'*»'»"-«o».  »  the 

ing  inflammation  i  th'e  he"  po  tn  ^T  "'"'  """■'  '^  '''""»''■ 
the  feeding-vessels  result  and  ICk  '""■  '"•*  °''»t™ction  of 
similar  eaustic,  may  b"  Led  to  ad  ^''  ""l  ^''™  »«'''•  »nd 
are  likely  to  ^main^nd  hfs  1,  ™  *\=  '"'  """^"'^  '-" 
very  objectionable.     VVhateve;  wHI  T!^  """"  "P""  *<>  '''"'«.  i« 

dry  up  the  substance,?the;irpretr:bTe''1r'^  ""^  *^^^ 
number  of  cases,  employed  .atisfacSte  actual''/"  "■«™' 
following  manner,  with  a  smrit  1  f  oautery,  in  the 

fixedinLodorc  n!  Then  .i;,^T  """  '  '"P"'^  "^  -«•!'- 
influence  of  chloroform      The  1!^',  T'^'  "  P"'  "ndcr  the 

and  then  with  ,uickne"s  introduced  TthTb^'f  ^  ""'^  '•^"' 
made  to  transfix  it.  This  is  oon,  V  ,  '*  "'  """  '""»■•.  "nd 
black,  lifeless  eschar.  I  have  tbl  ""  ""  """"'^  ""^»  '»  « 
rably  thick  coating  of  collodbn  1'"  """I  T''  '^"^'"^  ^  '"lo- 
tion to  signify.  The  CtTl  f  •"'?  '^°"°"'^^'  ""  '"A-mma- 
growth.  A  needle  withSZ,  "T''^  '"  """«"'»'»  *» 
tumor  at  its  base,  in  one  „r  two  i  '^  .T'''  '"  '™^«^  "■» 
together  as  to  completl  surroTn  J   7' .'"''  """  *'  ™'''  »"  "ed 

needles  may  be  .^Cai'lZZ  ^i  tSLf/  ''"^    '"' 
several  times  tightly.  ^'gature  wound  around 

ditfotwaroVrio':,;:' Th„"f"^ """  "■"  ■'  "-^ »-'  -pe- 

patient.     The  kuTmt    be  J    /"  '^"""""'^  ''''"°"  "^^  ''« 

structure,  else  .her  1^0  unnf       .  ITl  °""'^''  *^  °'-'"d 

ere  may  be  unpleasant  bleeding.    After  cutting. 


888 


PRINCIPLES    OP    SURGERY. 


should  any  portion  remain,  it  can  be  destroyed  by  the  caustic 
stick. 

Sarcomatous  Tumor;  Flesh-like.— Thia  is  not  so  well-defined  as 
some  other  class  of  tumors.  It  bears  a  close  resemblance  to 
others,  especially  the  fibrous.  It  is  quite  innocent  in  its  charac- 
ter ;  generally  round  in  shape,  with  an  uneven  lobulated  surface ; 
size  varies  from  a  hazel-nut  to  a  foetal  head ;  commonly  single  in 
number,  and  when  removed  completely,  it  does  not  recur.  No 
particular  part  of  the  body  is  liable  to  become  the  seat  of  growth. 


CHAPTER    XLVII. 

Cancerous  Tumors :  Kemarks— In  two  forms-Two  stages— Microscopical  ap- 
pearance.  Scirrhous :  Varieties— Colloid— Encephaloid— Epithelial— Course 
—Symptoms— Terminations— Effects  upon  constitution.  Treatment :  Local 
andGeneral— Extirpation— Caustic— Congelation— Pressure, 

Cancerous  Formations.— Thua  far,  in  the  consideration  of  tu- 
mors, attention  has  been  solely  directed  to  those  which  are  benign, 
or  which  manifest  but  a  tardy  disposition  to  malignancy.  The 
point  of  deviation  between  growths  which  are  innocent  and  those  , 
which  are  malignant  has  already  been  indicated ;  but  it  is  neces- 
sary to  acquire  a  more  distinct  idea  of  what  constitutes  malignant 
growths— in  what  respect  their  elements  differ  from  those  to  be 
seen  in  innocent  but  abnormal  formations. 

Pathologi/.— The  most  striking  characteristic  is  their  inclination 
and  power  to  grow  at  a  very  rapid  rate— much  faster  than  any 
natural  tissue  can  grow.  And  the  new  growth,  apart  from  its 
elementary  composition,  is  different  from  any  natural  tissue  of  the 
body,  although  it  may  bear  some  resemblance. 

It  would  seem  that  from  some  cause,  local  or  general,  more 
pabulum  than  could  be  appropriated  had  existed  in  the  part  at  first, 
and  that,  in  consequence,  the  original  cells  of  the  part  had  given 
birth  to  a  more  numerous  offspring  of  nuclei.  The  cells,  left  un- 
controlled by  the  circumstances  of  the  tissue,  continue  to  grow 
and  to  be  developed,  the  result  of  which  is  a  lusus  natural,  per- 


CANCEROUS    TUMORS.  ggg 

unTlTal  ^r/  el:^  ^"^^^^^"^  ^^^-^-«-     ^^^^  -and 
dition  of  inZ:     :;  ~^  ^'  ^-*  ^^*-3  to  a  con- 

ties.     It  now  begins  to  ;  ?  ''  P°'''''"«  ^^«tinct-  proper- 

life-blood.     Thts^^ew  i'^^^^^^^  ^^  *^^  —on 

croscope.     if  1  Vol^^^"*^'  '^^  ^^^  --^^*--  of  the  mi- 
natural  or  morbid,  can  be 
seen  cells  possessed  of  so 

tigh   a  vitality  as  in  the  —  r^ 

cancerous .  growth.      And  ^^^^'S 

those   tumops   which  grow      \j^fe^€Sl 
the  fastest,  as  the  encepha-         ^^^^^2?^ 

loid,   are   seen    to   possess  "^^B^^  A. 

far  more  active  cells ;  while  ^^^W^ 

on  the  contrary,  the  scir- 

rhous,  which  grows  less  ra- 

7        said  to  res.de  the  peculiarity  of  cancer. 


It  is  a  structure,  however  fnrm«^ 

are  endowed  wi'th  unttoTv  ^.r^"^!"' ""t^f  ™"* ''''-'' 
rapidity  of  its  erowth  «„A  ,,     "'"^r     ^""s  «  exhibited  by  the 

fatal,  the  malignLoy  A„d  w  °  ."f ''  *'"'  «™'""-'  ""«  "'"■•e 
farther,  it  is  f„td  lu  to  ret  sT/ed  ^'"^  "'  '"»  '""-  »'"1 
the  normal  structures  but  ail »/  ,  ' '"''"""  «°^1°al  with 

to  invade  the  neighborinlr't  "°""''"'  '''"'"'■  ^'  ""■"""■"'es 
to  absorb  the  tissi  :  d'to  ™  :™  'T  ."""^^'^  '°'  '"<■  "-^ 
itself.  The  blood  s  pk  ed  und'  °  /'f  °  '"'°""""'''  ''''^  "»'» 
expense  of  n„rn>al  ti^es  ™''  j;°."'"*"".«».  a-l  gives,  at  the 
cancer.  '  '"  *«  ■"'Perative  demands  of  the 

Cancer  is  unlito  the  tumors  heretofore  considered.     They  were 


If. 


If 


ft 


I" 


u 


390 


PRINCIPLES    OF    SURGERY. 


but  local  affections,  due  in  the  main  to  local  causes ;  but  cancer  is 
a  constitutional  affection.  The  tumor  is  only  a  local  manifesta- 
tion of  the  general  morbid  diathesis.  And  what  is  this  diathesis  ? 
what  is  its  origin  ?  whence  the  fearful  malignancy  which  displays 
itself  in  draining  the  life-blood,  and  exhausting  the  powers  of  life, 
never  resting  satisfied  until  the  life  of  the  individual  is  at  an  end? 
Unfortunately  pathology  has  not  yet  uncovered  the  cause  of  the 
malady.  The  disease  is  as  mysterious  as  it  is  fearful ;  in  its  ori- 
gin it  is  as  uncertain  as  its  end  is  certain  and  deadly.  The  dis- 
ease may  be  said  to  be  local  in  this  respect :  the  great  error  seems 
to  be  located  in  the  blood.  Looked  at  by  the  naked  eye  nothing 
can  be  discovered,  yet  this  fluid  possesses  something  unnatural  or 
is  wanting  in  something  essential  to  true  vitality. 

The  disease  is  hereditary  and  may  be  transmitted  down  through 
many  generations,  yet  it  would  seem  often  to  arise  spontaneously, 
and  to  possess  quite  as  much  malignancy.     There  is  very  slender 
proof  that  the  disease  may  be  communicated  from  one  individual 
to  another.     It  is  neither  possible  nor  desirable  to  introduce  the 
different  views  of  eminent  writers  on  pathology  respecting  cancer, 
but  I  will  give  those  advanced  by  Mr.  Simon,  in  his  "  General 
Pathology."     He  says :  "  Thrust  aside  all  the  accidents  and  trivi- 
alities of  the  subject,  strip  the  question  naked,  and  what  does  a 
cancer  mean  ?     Substantially  it  is  a  new  excretory  organ.    Under 
the  pressure  of  some  mysterious  constitutional  necessity,  a  growth 
arises  which  (in  its  typical  form)  tends  essentially  to  acts  of  elimi- 
native  secretion,  just  as  distinctly  as  the  healthy  liver  or  the 
healthy  kidney.     You  must  not  stop  short  at  the  tumor;  you  must 
scan  the  whole  drama  of  the  disease,  in  which  the  tumor  forms  but 
a  proremium.     Look  again  at  such  a  case  as  I  gave  you  for  illus- 
tration— a  case  of  encephaloid  manifested  in  the  globe  of  the  eye, 
that  vast  fungating  ulcer  which  ensues  on  the  protrusion  of  the 
tumor,  and  which  continues  hourly  to  purge  forth  its  profuse  dis- 
charge— that  is  the  real  intention  and  purpose  of  the  tumor,  as 
palpably  as  urine  expresses  the  intention  of  the  kidney,  or  bile 
the  intention  of  the  liver.     The  cells  of  the  tumor  have  grown 
like  healthy  gland-cells— like  the  nucleated  cells  of  a  mucous 
membrane,  only  to   discharge   themselves   with   their   contents. 
There  is  nothing,  I  repeat,  like  hypertrophy  in  the  disease;  it 
consists  essentially  in  the  establishment  of  a  new  vent — a  new 


CAHCBROUS    TUMORS. 


391 


tus  lor  the  formation  of  deciduous  cells." 
-Sfas^a.-Cancerous  growths  may  be  said  to  have  two  stages- 

he'  t:J;  I  *"'•  "'  ^'-'"P"'-'.  '"'  —d  of  maturity  Sg 
the  first  there  is  generally  a  good  degree  of  firmness,  and  dur  ng 
the  second  there  is  a  tendency  to  softening.  ^ 

The  morbid  material  is  not  always  in  the  form  of  a  tumor  it 
may  .nstead  be  deposited  in  the  tissue  of  an  organ.  In  Mela  tter 
ej«e  the  course  is  less  rapidly  run,  and  it  is  n't  possessed  of  so 
much  mahgnancy.  The  cancerous  mass,  speaking  generallv  is 
composed  of  a  fibrous  framework,  more  or  Js  extetrra^d  o'f  a 
flmd  ahve  w.tb  cells.  This  fluid  is  called  the  can^J  Z  Of 
c  urse,  the  more  there  is  of  the  fibrous  element  the  more  fiTm  wH 

Castro::' ""'  "■'  "^  "■'""^'  "•'  '^'^  "■- "''  "■»  >-  ^e 

Micro,copioal  Appearan,e.-Vni,.r  the  microscope  the  follow 
mg  are  found  to  be  the  characteristics  of  the  can    rTui        The;' 
are  "  essentially  forms  and  steps  of  microscopical  cell-grow  h 
round  or  oval  cells  like  pus-globules,  with  dotty  contents,  af  d T  th 
a  nucleus  more  or  less  distinct,  or  cells  like  those  of  glandHr 
gangha  more  opaque  with  granular  material,  round  or  angular 
or  developed  into  processes,  and  having  one  nucleus  or  set  fa  "; 
g.gant,c  mother  cells  containing  within  them  simple  cellsof  anew 
formation,  nuclei  and  granular  matter,  or  cells  in  various    egreel 
0  bl.ck,.ess  with  pigment,  perhaps  to  an  amount  which  shall'  e" 

Zl^il^t^'^T'""""''  "'  'P'-'J'-^.ped  bodies  with  0  d 
nuclei,  indicating  the  commencement  of  new  fibre,  or  free  nuclei 

ml  gland  cytoblasts,  others  twice  or  thrice  as  large,  elliptical  with 
double  nucleoli  or  elementary  granules  of  all  sLs,  or  glomeruli 
consisting  of  them  And  for  the  intercellular  material,  ft  Z  no 
high  development  in  snch  cases ;  sometimes  it  will  be  so  LorpI  ous 

t  will ;:::;'' «'"',*;  """"""""  ca„„„t  identify  it,  somet 
It  will  be  more  fiiie<l,  but  scarcely  more  shaped,  having  the  faint- 

ir~  IT' ""'  °""^'°« ' '-  ^'™«""''  -^^  ^ 

As  before  stated,  the  heterology  of  cancer  does  not  consist  in  a 

dissimi  arity  in  the  ultimate  constituents  of  the  mass  f  oma     .h„: 

J.  ,iu  DOvj,,  uv,  ^ci  in  anj caeuucai  deviati )n.    Kuther, 


I 


■    m 


392 


PRINCIPLES    OF    SURGERY. 


It  IS  in  the  crowded  state  of  the  microscopic  cell,  the  variety  and 
number  of  which  are  at  once  seen,  and  which  manifest  such  a  lively 
activity,  leading  to  such  unnatural  growth  of  the  mass. 


"■"-"^^c^ 


Varieties.— The  cancerous  disease  presents  itself  in  different 
forms,  as  to  consistence  and  to  external  appearances.  The  whole 
can  be  well  enough  presented  by  speaking  of  the  scirrhous,  the 
colloid,  and  the  encephaloid,  also  the  epithelial.  Again,  cancer 
may  be  a  primary  growth  or  a  secondary  formation. 

Scirrhus  Cancer  is  characterized  by  great  firmness  of  struc- 
ture, the  fibrous  element  being  largely  in  excess  of  the  cancerous 
juice,  therefore  the  growth  ia  less  rapid,  also  there  is  less  malig- 
nancy.     The  stroma  frequently  is  composed  of  the  original  tissue, 
that  is  to  say,  the  morbid  material  had  been  deposited  in  the  inter- 
stices of  the  tissue,  although  after^a  time,  from  the  presence  of 
the  deposit,  the  network  had  become  quite  changed  in  its  nature 
and  appearance.     The  tissue  in  which  the  disease  exists,  as  well 
as  the  structures  immediately  around,  will  often  give  ehnructer  to 
the  mass.     The  greater  the  degree  of  resistance  the  greater  the 
effect  produced ;  consequently  the  outside  view  of  the  mass  and 
the  appearance  on  section,  will  in  one  oass  »>re3ent  one  form 1 


CANCEROUS    TUMORS. 


393 


in  another  case  another  form.     Hence  a  variety  of  names  have 
been  given  to  this  species  of  cancer,  based  entirely  ZZleZ 
rangement  of  the  fibrous  stroma,  which  arrangement  LTue  to  the" 


character  of  the  pressure  to  which  it  had  been  subjected 
the  tumor  may  be  lobulated,  beinir  intor«nn..l  ,»,  3 


3,  or  it 


Thus 
may 


(, 

i 


I 


394 


PRINCIPLES    OF    SURGERY. 


be  of  a  mammary  form,  so^  called  because  of  resemblance  to  the 
mammary  gland ;  or  the  pancreatic,  like  the  pancreas ;  or  it  may  be 
reticular  in  form ;  occasionally  it  has  an  alveolar  arrangement,  also 
ncepiform,  turnip-like.  Then  there  is  the  lardaceoua  variety,  which 
"  closely  resembles  a  section  of  the  rind  of  fresh  pork."  (Gross.) 

Habitat.— The  most  frequent  habitat  of  scirrhus  are  the  female 
breast  and  the  uterus,  the  lips,  the  stomach  at  the  pylorus,  the 
rectum,  the  penis,  and  sometimes  the  bones.  I  had  a  case  but 
recently  where  the  whole  of  the  intestines  were  involved. 

Colloid  Chancer.— This  is  a  variety  of  less  frequent  occurrence 
than  either  of  the  others.     It  is  characterized  by  a  gelatinous, 


jelly-like  appearance,  and  is  made  up  of  a  deli- 
cate fibrous  framework,   which   contains   the 
gum-like  juice.     The  greater  the  quantity  of 
fibrous  element,  the  more  firm  the  cancer  will 
be.    The  substance  within  is  quite  transparent, 
colorless,  and  is  likened  to  the  crystalline  lens. 
(Simon.)     It  may  be  seen  sometimes  standing 
out  on  the  surface  like  the  translucent  gum  of 
a  balsam  tree.     The  deposit  more  commonly 
takes  an  alveolar  arrangement ;  and  hence  it 
is  often  called  alveolar  cancer.     It  may  exist 
in  the  form  of  a  distinct  tumor;  or  it  may  be 
infiltrated.     The  colloid  cancer  is  met  with  in 
the  stomach,  rectum,  upon  the  omentum,  in  the 
bones,  ovaries,  and  kidneys. 

Encephaloid  or  Medullary  Cancer. — In  this 
form  is  seen  the  widest  departure  from  normal 
structure.     The  mother  cells  are  the  largest, 
and  the  most  crowded ;  the  nuclei  and  granules 
the  most  numerous  and  varied.     It  is  of  all  the  most  mali<'nant 


CANCEROUS    TUMORS. 


395 


with  whi  t  pCr,' :?™  f  ""T'  ^-^  '"^  «■-^-- 

for  the  great  JaZ^^t.u     Hoodvesseb;   a  condition  necessary 
of  vessel  t  TT^,  1  '^'°'"""'  """•     Son,etimes  the  number 

»«<.r  The  c  ats  of  theT'T  "  """"°"'^  "''"^<'  ^''"*'"  *- 
gro,  It  IS  a  natural  constituent  of  the  skin      Thl ,  j- 

:rt^  appiied.  This  is  *:  t-hrainr:r i::^^ 
divIfeVrtTrjes^  titf;':™;;- "  :"■""•  "^  ^'  --^ '"  ^  -^ 

-Tin,  _h,a„c:  To'r  Lra::rr:rMrrt 

//aie^a^-The  parts  of  the  body  in  which  the  encephuloid  most 

from  the  breast,  the  testes,  likewise  the  limbs.    It  may  arise  how- 
ever,  m  almost  any  part  of  the  body.  ^  '    ^ 

At  first  the  growth  mav  ho  deen-pa*--!   -^-i    - 

^  _ -  att-^j  yt-dvcu,  aim  iis  nature  undis- 


396 


PRINCIPLES    OP    SURGERY. 


covered,  but  eventually  approaching  to,  and  then  standing  out 
trom  the  surface,  a  rapidly  growing,  livid,  soft  formation,  its 
character  will  no  longer  remain  unknown. 

Epithelial  Cancer.— ^m^  affection  is  in  several  respects  different 
from  either  of  the  afore-discussed.  Its  name  indicates  that  the 
habitat  of  the  disease  is  in  membranes  with  an  epithelial  covering 
It  is  upon  the  ski  1  and  mucous  membrane,  membranes  exposed  to 
air,  that  it  is  almost  altogether  met  with.  Not  only  is  it  singular 
in  this  respect,  but  also  in  being  far  less  malignant  than  any  other 
form.  Indeed,  it  is  questioned  by  some  whether  this  should  be 
classed  among  cancers,  inasmuch  as  it  seems  to  arise  without  any 
perceptible  constitutional  cancerous  diathesis.  It  is  proposed  by 
some  to  call  it  epithelioma  or  cancroid.  Again,  as  it  closely  re- 
sembles  scirrhus,  it  might,  at  least  it  has  been  included  among  the 
scirrhous  variety. 


The  general  appearance  of  this  tumor  is  that  of  "  an  exuberant 
warty  growth,"  presenting  a  pale  white,  reddish  color.  Sometimes 
It  has  a  smooth  surface,  but  more  frequently  it  presents  a  peculiar 
tuberculated  form,  with  perhaps  ulcerations,  and  dark  red  crusts 
on  their  exterior. 

As  before  stated,  it  seems  to  have  a  preference  for  the  skin  and 
mucous  membranes,  especially  at  the  mucous  orifices.  The  most 
common  seat  is  the  face,  particularly  the  lower  lip,  but  it  also 
comes  at  times  on  the  tongue  and  the  cheeks ;  occasionally  it  forms 
as  well  m  the  larynx,  pharynx,  and  trachea.     Another  common 


CANCEROUS    TUMORS. 


397 


the  female  it  may  arise  in  thp  ^.11.  „f  .t  generation.     In 

neck  of  the  uteris  in  ,L  f        ?         v*""  ''*«'"'^  ""^  "''»"'  ""e 
■        The  Hi..!.   •       ■?         °"°  "^  *  »™'ifl»»er  excresoence. 

in  Jhe  fer:::  "  ""■  '°  ""™'  "■"'  ^-^-''^  ■«  «•»  male  than 
tha^rt!!''.'/'"''''^  '"^'^  ""■  ''''P^"'  *"  ">!»  f»™  of  the  disease 

X:  /o:;ir  ""'t  "-"^  '°°^'  """^  ™  "-s^ ": 

is  a  common  case  of  th^^'  ""'"'^'^  "  ^'""  "'«'  "''^  W^' 
the  scrotum  itTsfrelXdIT  "":"  "^  '""^  '■"•  ^'^"™ 
"hich  the  chimne;  :  jtetVs  ;°  luh!  'T'.f "''  °'  ""''  '" 
cancerous  diathesis  vet  it ,,  nT   «  •      ,"'°»8''  "■'■'e  "igl't  be  a 

.  local  disease^  ^'not  ome  „„1"; Tf^  '""'"'""'  '»  ""S'™'" 
lead  to  it.  °''''  ""'^  '""g-coutinued  irritation 

betnTd'eKr'thTt  ''^'"'T  "^  '^""--There  are  to 
designated  selXfXrnT  '"'  -°-'>^' '^-  which  are 

a  few  months  X;  atirrtr  f""'^'"'"''  """^  ™  "'  «»"-  ^ 
a  long  series  ^f  years  .Td  "1  ."°'"'°'  "f  ^^'^^  """y  """"Py 
venefo  Cose  the^ati™" Itrng'  ""  """"  "^^  '""' 

wif :;  '::e':x ;;:  ^-'^  'vr  s^-""  «""■•  *«  encc. 

many  cLs  of  cfuceT  p'eatgj:,,"'.!:??^  ri""'-     '" 
tient  will  have  of  the  existence  of*^'    *  ^""""edge  the  pa- 

V  shooting  pains  in  ^c^^inZr-^c^iri:;:^'' 
dis.essi„g.  that  KLrr  •  leX^sf:::'  :ir "-' 
paiL,anZteaJof\r:;i;yirr;t^^^^^^^ 

It  is,  indeed,  attaching  itself  fn  1^         '  Z     ^^'"""^  "^''^  ^^^d. 

into  it  p-io;gatio„:t:r  Lia  ;z:t/it'r:' ''  ^-'"-^ 

--cturc.    At  this  time  L  gianis  n^rtX  ^^trX;; 


398 


PRINCIPLES    OP    SURGERY. 


likely  receive  deposits  of  cancerous  material  in  their  structure. 
The  size  of  the  tumor  occasionally  may  suddenly  increase,  from 
inflammatory  action,  and  again  resume  its  previous  condition; 
but  on  the  whole  the  growth  will  steadily  advance.  Often  one 
portion  will  grow  more  rapidly  than  the  other.  Although  at  first 
quite  subcutaneous,  and  unattached  to  the  skin,  it  ultimately  in- 
volves that  in  the  disease.  The  tumor,  now  upon  the  surface,  and 
standing  out,  will,  in  many  cases,  lead  to  ulcerative  destruction  of 
the  surface,  perhaps  to  sloughing,  forming  an  ulcer  of  a  most  loath- 
some nature.  From  this  will  continue  to  pour  a  bloody  pus,  mixed 
with  detritus.  The  mass  continuing  to  extend  to  parts  around, 
will  literally  eat  them  up  and  pour  them  out  in  the  foul  ulcer. 
It  is  when  the  cancer  is  thus  open,  that  the  term  "  cancer"  may 
be  more  appropriately  used.  Death  may  soon  come  from  this  in- 
cessant drain  upon  the  system ;  and  the  pain  will  assist  to  pros- 
trate the  system.  But  death  may  come  in  a  more  speedy  manner 
by  the  cancer  eating  into  a  large  artery,  and  producing  hemor- 
rhage. A  generally  recognized  symptom  of  the  cancerous  diathe- 
sis is  a  sallowness  of  the  skin.  In  cases  of  tumor  of  doubtful  cha- 
racter, this  appearance  will  assist  in  the  diagnosis. 

The  course  and  termination  of  the  encephaloid  is  marked  by  more 
fearful  symptoms,  and  is  more  quickly  fatal.  It  will  often  spring 
up  like  a  fungus,  spontaneously  perhaps  from  a  cavity  about  the 
face,  or  from  the  head ;  sometimes  it  will  arise  from  an  injury,  or 
a  wound,  instead  of  healing  by  granulation,  sends  forth  malignant 
sprouts,  which  will  grow  apace,  as  if  the  disease  had  waited  such 
an  outlet  by  which  to  manifest  itself.  Very  soon,  in  whatever 
way  the  disease  arise,  the  structures  around  become  a  part  of  the 
mass.  The  discharge  will  be  mostly  the  same  as  that  seen  from 
the  open  scirrhus.  The  tumor  is  more  soft  than  the  scirrhus, 
and  the  pain  much  less.  Exhaustion  and  death  cannot  be  long 
delayed. 

The  epithelial  cancer  is  slow  in  its  course,  and  doubtful  in  its 
result.  For  a  long  time  it  may  be  uncertain  whether  it  is  malig- 
nant or  not.  But  when  it  does  attain  to  true  malignancy,  it  ex- 
hibits characteristics  no  leds  destructive  and  uncontrollable  than 
that  which,  at  the  first,  displayed  its  true  character.  Cases  have 
come  under  the  notice  of  almost  every  surgeon,  where  the  disease, 
coming  perhaps  upon  the  lip  or  the  cheek,  and  for  a  long  time 


CANCEROUS    TUMORS. 


899 


seeming  to  be  only  a  warty  growth,  has  slowly  but  surely  extended 
mward  and  to  parts  around.  At  last  it  ulcerates,  and'^s  covered 
by  a  cream-hke  fluid  resembling  pus.     It  continues  to  extend,  eat- 

'  B  now  a"„Il!  7  '"  '*r'"'''  ''*'*"^«^'  I'^^^'-everytLing. 
•  tb7.  .t  rT  ^PP'"'  *^'*  ''''''''''''  inflammation  is  induced 
in  the  epithelial  cancer  at  an  early  date,  before  it  has  had  a  con- 
verting  influence  upon  the  adjacent  tissue.  The  inflammation 
destroys  the  morbid  mass,  and  the  disease  is  averted.  The  ulcer 
remaining,  heals  up  in  a  healthy  manner.  This  unfortunately  is 
ot  rare  occurrence.  ^ 

Weots  upon  the  Constitution.-NotmthBtmdmg  the  disease  is 
a  constitutional  one,  and  that  the  seeds  of  the  m'alady  willTav 
been  long  sown,  yet  the  individual  will  have  experienced  no  illness, 
ho  rV     ^^'^^*^^*  «y-P*0"»  had  whispered  to  him  the  coming 
horror  of  a  cancer.     Every  organ  and  its  function  will  have  been 
perfectly  normal,  until  the  local  manifestation  presented  itself.  But 
very^soon  thereafter  the  hitherto  latent  disease  displays  itself  in 
constitutional  symptoms,  which  seem  to  arise  entfrely  from  the 
local  deposit.     We  have  learned  that  the  cancer  mass  may  b!pri! 
mary  or  secondary ;  and  that  first  there  is  generally  but  one,  while 
m  the  secondary  there  may  be  several.     In  order  to  have  the  se- 
condary deposits  made,  there  is  generally  an  actual  passage  of  the 
cancer  substance  from  one  place  to  another.     During  the  progress 
of  the  disease  thus  indicated,  whether  the  original  virus  in  the 
blood  18  being  intensified  by  the  local  disease  as  well  as  by  develop- 
ment,  may  be  questioned,  but  this  much  is  true,-at  once  after  the 
local  disease  is  established  the  powers  of  life  begin  to  sufi-er-to 
tan.     Ihe  great  pain,  and  subsequently  the  discharge,  contribute 
argely  to  the  general  cachexia,  also,  no  doubt,  consciousness  on 
he  part  of  the  patient  that  his  malady  is  incurable.     The  consti- 
tutiona  cachexia  IS  always  better  marked  in  the  encephaloid  form. 
Treatment  of  Cancer-Local  and  aeneral-The  sad  fact  that 

epithelial  form;  and  it  is  an  aff-ection  over  which  nature  seemingly 
has  no  control.  But  very  much  can  be  done  by  the  surgeon  to 
palliate  the  symptoms,  and  often  to  prolong  life 

It  might  seem  that,  as  the  disease  may,  and  often  does  remain 
laten  for  a  long  time  without  manifesting  itself  locally,  the  re- 
moval  of  the  local  deposit  when  possible  would  arrest  the  malady 


400 


PRINCIPLES    OF    SURGERY. 


at  least  for  a  time.     But  unfortunately  experience  has  proved  that 
such  is  not  to  be  expected.    There  is  hardly  one  well-authenticated 
case  recorded,  in  which  removal  of  the  cancerous  mass  had  the 
effect  of  staying  the  disease.  '  Having  once  exhibited  itself,  it  is 
no  longer  willing  to  remain  in  obscurity.    Finding  itself  possessed 
of  power  to  grow,  and  to  outgrow  normal  tissue,  it  will  soon  seek 
and  find  another,  or  several  other  localities,  wherein  to  assert  its 
power.     Indeed  it  would  seem,  at  least  in  many  cases,  that  the 
removal  of  the  primary  tumor  aroused  the  disease  to  a  more  ener- 
getic action.     This  fact  has  led  some  to  say,  that  if  the  primary 
tumor  remain  untouched,  the  disease  will  display  less  activity, 
and  the  patient's  life  be  more  prolonged  than  when  removal  is 
made,  to  be  followed  by  the  more  malignant  secondary  deposits. 

With  regard  to  the  removal  of  single  primary  cancerous  tumors, 
it  is  not  well  to  lay  down  a  general  rule.  If  the  tumor  is  exposed 
and  painful,  or  a  cause  of  great  inconvenience,  the  surgeon  may 
the  more  readily  determine  to  advise  its  removal ;  but  it  will  be 
preferable  to  lay  the  matter  fully  before  the  patient  and  his 
friends ;  and  then,  although  guiding  their  judgment  to  a  great  ex- 
tent, be  guided  by  their  wishes.  The  family  history  must  be 
taken  into  consideration ;  if  there  be  no  evidence  of  family  predis- 
position, probably  the  growth  will  not  so  speedily  return,  if  re- 
moved. Of  course,  should  any  other  disease  exist,  which  might 
interfere  with  the  success,  removal  will  not  be  undertaken.  The 
tumor  must  not  be  too  large,  and  it  must  be  circumscribed  some- 
what. 

Having  decided  to  remove  the  mass,  care  must  be  taken  to  se- 
cure a  complete  extirpation.  Often  there  will  be  prolongations, 
roots  dipping  down  into  the  tissue  around;  these,  so  far  as  possi- 
ble,  must  be  removed.  Again,  very  often  the  glands  in  the  vicin- 
ity are  the  seat  of  deposit,  and  must  also  be  removed.  Sometimes 
a  limb  will  be  so  involved  that  the  only  effectual  way  of  extirpa- 
ting the  disease  is  to  amputate  the  limb  above  the  disease. 

As  to  constitutional  treatment,  it  has  already  been  stated  that 
cancer  is  incurable,  that  at  present  there  is  no  remedy  known 
which  will,  by  internal  administration  or  by  application,  cause  a 
dispersion  of  a  cancerous  growth,  or  to  any  extent  arrest  it  in  its 
disastrous  course.  While  medicines  may  often  be  given  to  ad- 
vantage to  palliate  distressing  symptoms,  as  anodynes  to  relieve 


CANCEROUS    TUMORS. 


401 


good;  while  ,n/h'^^'  ''?«7°' g™"  »o  fet  when  the  health  is 
see  that  the  ZfonJ  oj"/'""?^"'^'',™' '"''•""»»* '"O-i.  »«> 

f».ffl  these  i„drt?„;,Tr;j:::;st'r':°'  """""•.  ^° 

(St  alkalies,  or  iron  nr  ^hu  •       ™1™™  '"  8'™  'orncs,  or  iodine, 
the  sys.en,'ra;de™,d    """'■  """"'"^  "  •''"^■'  -■««'■»-  «f 

wsXo:r:::',rr:,ts  Tar  "t-  -^r'^^  '•">  ^» 

comfortable  as  may  be  .„T,       ,■■'  Z'  '°  ""''"'  ""«  P""  " 

a  tnmor,  it  I:i7bo  CXvtb  T'  ""'  «™""'  ''  ^«« 
apparatns.    Nothing  shonH  b!    \\^^'^ee,  or  some  suitable 

riate.  Too  often  8,f.b  ,•'''"*  *■■*'  ""'  '"'"'^  »■•  e«o- 
symptoms  OpTumTn  some  f ''''°°'  T  "'°'''  "■">  W.™««  *>■« 
most^dtable  aXrn  '^"™' fet''  ""^  "''•''°-"'^'  "  «" 
charge  issnes,  s^S,  .heTreatre^^rpriUatetl  """  '  '"^ 
tmg.    Protect  the  part  attend  t„  ,1,7/7  ^  "on-irnta- 

siould  threaten,  or'aet  aly  cl^  take  the"^''  '"* ''  "''^"'g 
arresting  it,  if  oossible      Z         •      ,  "oceseafy  steps  for 

'ead  lotL  ;>„  SfXd^rS  Ct'  "»f  .in-  "J 
zmc,  trisnitrate  of  bismuth  "  nr  «  c-     i    ^'°*°"-       ^^^  oxide  of 

plied  in  the  for.  of'  oTde;  ol-JZ^^^'Z:!! ^^  ''  ''' 

The  use  of  Caustic -Th^  uJTf        I'   j^^'*®"^  ""^  Surgery.) 
favor.     In  1857  Dr  fJi     T'^^T"'''  ^"''  ^^*^  ^^'^^^  obtained 

remove  a  portion  of  the  mass  theVal^  to  extirpate,  or  to 

mass,  the  hgature  may  be  made  to  em- 


z(> 


402 


PRINCIPLES    OP    SUROERY. 


brace  the  desired  portion.  But  in  all  of  these  cases  it  will  be 
remembered  there  will  remain  a  space  more  or  less  great,  to  be 
closed  up,  if  closed  at  all,  by  the  healing  process;  and  it  can 
scarcely  be  questioned  that  this  is  more  likely  to  be  accomplished 
quickly  after  removal  by  the  knife. 

Pressure  has  been  employed  to  dissipate  cancerous  tumors,  and 
according  to  some,  has  led  to  considerable  reduction  in  the  size  of 
the  tumor.  The  pressure,  if  made,  must  be  regularly  diffused, 
and  unattended  with  any  irritation  of  the  part,  or  inconvenience 
to  the  patient. 

Treatment  of  Upithelial  Cancer  will  be  somewhat  different  from 
that  recommended  for  cancers  generally.  This  would  be  expected 
from  the  great  difference  which  exists  between  the  two.  In  the 
first  place,  when  an  epithelial  cancer  is  beginning  to  form,  very 
often,  by  doing  away  with  the  cause — some  irritation— the  growth 
may  be  arrested,  and  therefore  be  gradually  absorbed.  The  irri- 
tation may  arise  from  smoking,  or  exposure  to  soot,  as  in  the  chim- 
ney-sweep, or  it  may  be  due  simply  to  continued  manipulation  on 
the  part  of  the  anxious  patient,  to  see  if  it  is  growing.  I  have  seen 
not  a  few  cases  in  which  suspicious  growths  were  observable  about 
the  face,  and  growing  apace,  but  which  ceased  to  grow  upon  being 
let  alone.  Not  only  are  these  often  made  to  grow  by  constant 
feeling  of  them,  but  more  particularly  hy  using  all  sorts  of  appli- 
cations  "to  drive  them  away."  All  such  should  be  steadily 
avoided. 

When  an  epithelial  cancer  is  undoubtedly  growing,  it  ought  at 
once  to  be  removed  by  excision,  thorough  excision.  The  chances 
are  it  will  not  return,  yet  sometimes  it  does. 


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